
Book J& 5— 



Copyright N° 



COPYRIGHT DEPOSIT. 






LIBRARY of CONGRESS 
Two Copies Received 

OCT 22 1906 

^ Copyright Entry 
CUSS /4XXC, No. 

IS 17} 1 

COPY B. u . 



Copyright, 1906, by C. V. Mosby. 



PRESS OF 
FLEMING PRINTING CO. 
ST. LOUIS 



TO 
MY FRIEND 

CHARGES H. MAYO, M. D., 

OF 
ROCHESTER, MINN., 

WHOM I ADMIRE AS A SURGICAL ARTIST, 
I DEDICATE THIS LITTLE BOOK. 



HE HAS EYES THAT FEEL AND FINGERS THAT SEE. HE 

TEACHES ALL THAT HE HAS LEARNED IN THE 

ONLY POSSIBLE WAY ONE MAN CAN TEACH 

ANOTHER— BY LETTING THE OTHER 

SEE HIM WORK ; AND HE 

WEARS NO CLOAK ! 



CONTENTS 



Page 

Preface - - -, - - 5 

The Education of a Surgeon - 9 

On Scientific Contributions to the Liter- 
ature of Medicine and Surgery - 21 



Science and Surgery - - - 3 



On Ways and Means of Building up a 

Practice 43 

About Fees - - - - 50 

Off with the Cloak of Superstition -• 52 

Some Golden Rules of Surgery - 59 

Away with Inflammation and the Con- 
fusion It Has Caused - - 173 

Reminiscences - - - - 219 

See index for details. 



ADVICE TO A YOUNG MAN ABOUT TO BE- 
COME A SURGEON. 



The problem of the evolution, education, or if 
you please of the making, of a surgeon is a ques- 
tion which has always greatly interested the pro- 
fession. I am one of those who agree with the 
view of OslER that the creative, pathfinding, or 
epoch-making ideas come to all men before they are 
forty years of age, although some may not pub- 
lish or elaborate them until they are older. I 
am therefore of the opinion that the making or 
education of a surgeon should begin early. I am 
convinced that a silk purse cannot be made out of 
a sow's ear and I know that the gold must be in 
the ore, or no process of refinement can possibly 
evolve or extract it. I know, however, that some 
young men with very limited training, often out- 
strip some of their fellows who have had great 
scholastic advantages. There must be something 



10 GOLDEN RULES OF SURGERY. 

in these untrained men which schools and lessons 
and other educational processes could not supply. 
Exactly what this something may be is very hard 
to say. My opinion, in a few words, is that the 
young person must belong to that type which Mr. 
HadlEy, the President of Yale College, has called a 
fact-seeker. The young person, male or female, 
must be one of those whose hands, as well as 
whose brain has been educated. I may be better 
understood if I say, — he must be one of those who 
has learned to use his five senses. His eyes, his 
sense of feeling, of hearing, of smelling and of tast- 
ing, must be capable of a development far above the 
average. He must be able to arrive at correct con- 
clusions by accurate observation, that is, by using 
his senses. We have recognized that the highest 
function of a surgeon is to make a diagnosis. The 
ability to treat disease is entirely dependent on the 
recognition of the pathological condition. The 
operator will always rank just next to the diag- 
nostician but can never be considered to stand 
higher than the diagnostician. It is well and much 
to be striven after that both functions be combined 
in one man, but experience has proven that two 
can be relied upon better than one alone. It is 



THE EDUCATION OF A SURGEON. 11 

wise to have two kinds of talent in ail obscure 
cases. Obscure and dangerous cases tend to make 
us modest, so that the suggestion of calling con- 
sultants is more readily accepted. In simple, clear 
cases, consultations are not only useless but often 
directly harmful. 

Besides being a man of educated trained senses, 
I think the young person taking up the study of 
surgery should be self-reliant, full of sympathy with 
mankind and last but not least, should have a love 
for acquiring scientific truths. In addition to these 
basic traits every quality of mind which would 
make an honorable, cultured gentleman would be 
desirable. 

It seems to me that an education in a scientific 
school such as Sheffield or the Boston school of 
Technology would fit a young man better for the 
life work of a surgeon than a college course lead- 
ing to the A. B. degree. At institutions like those 
mentioned, physics and chemistry are taught, with- 
out which an understanding of biology and phys- 
iology is simply impossible. 

The education of young gentlemen in Amer- 
ica, will lead to the making of a better class of 
surgeons than an early education in Continental 



12 GOLDEN RULES OE SURGERY. 

Europe or England, in the fashion prevailing there 
at the present day. At country parties in Europe 
I have seen young gentlemen absolutely helpless 
in cases of accident. They could neither saddle 
a horse nor unhitch a team in an emergency, al- 
though they were stylish riders and drivers. You 
must know that the European gentleman has his 
sons and daughters trained in riding, driving, 
swimming, shooting, etc., by a teacher from whom 
they receive lessons in these arts. Our American 
boy learns these accomplishments by hard experi- 
ence, which after all is the best school. In most 
cases we learn to shoot, by virtue of disobeying 
our parents, and so it is with other accomplish- 
ments of a sporting and athletic character. Our 
boys are therefore more practical and useful in an 
emergency and are more resourceful when it 
comes to using their hands in case of accident or 
in a surgical operation requiring manual dexterity 
and a cool head. 

Our young man is now ready to enter a medical 
school and the first year ought to be devoted to 
anatomy, physiology, embryology and organic 
chemistry. In the second year he begins pathol- 
ogy and continues histology both normal and path- 



THE EDUCATION OF A SURGEON. 13 

ological. During these two years nearly all his 
time should be spent in the dissecting room and 
the laboratories. Pathology of course includes 
bacteriology. 

Having taught anatomy for eighteen years in 
various medical colleges, I may be permitted a few 
remarks about the study of this science. Anatomy 
is the discipline which teaches the structure 
of organisms. Medical men have always looked 
upon it as an auxiliary science, a sort of handmaid 
to medicine, because upon it is based the art of 
surgery. Until recent years our knowledge of 
anatomy depended upon the dissection of human 
and other animals. When we look back over the 
field we are more and more astounded at the enor- 
mous number of facts we have learned about the 
structure of the human and other organized bodies 
by dissection. Until recently our knowledge rested 
on microscopical and macroscopical dissection. Re- 
cently the modern science of embryology has 
given us a more stable and scientific basis for our 
anatomical work. Suppose you are desirous of in- 
vestigating the structure or construction of a com- 
plicated machine, say for instance a man-of-war. 
Is it not at once clear to you that you can under- 



14 GOLDEN RULES OF SURGERY. 

stand its structure much better if you watch the 
building of such an engine of war, than if you tear 
one to pieces or dissect one? There can be no 
doubt about the best method to pursue. Watching 
the development and construction of a complicated 
machine to its completion will at once give you an 
understanding of all its parts and functions, where- 
as the mere dissection or taking apart of one will 
not give you this understanding, although it will 
acquaint you with its parts. 

Remember that anatomy which is learned by 
memory is easily forgotten and is often useless, 
but anatomy which you have grasped by your 
reason and understanding will last forever. For 
example let us take a question in anatomy: Why 
does the recurrent laryngeal nerve dip down into 
the chest forming a long loop around the arch of 
the aorta on the left and around the subclavian 
artery on the right in order to reach its end in the 
muscles of the larnyx which govern the voice? A 
man who has studied embryology at once answers 
the self-evident question ; an anatomist whose 
knowledge rests on dissection cannot answer at all. 
Let hie therefore caution you again — do not depend 
on anatomy which you have committed to mem- 



THE EDUCATION OF A SURGEON. 15 

ory, but learn anatomy by using your sense of un- 
derstanding and of reason, as well as the sense of 
seeing and feeling. Learn to understand the struc- 
ture of the body, on which depends your ability to 
do surgery, by studying its development from the 
egg stage to completion. Your knowledge of an- 
atomy and of physiology must not depend upon 
what you read in books; it must be founded on 
observations made by yourself by the use of your 
senses and the use of instruments of precision. 
You can have no scientific knowledge as long as 
you depend upon the authority of books and lec- 
tures. Science abhors authority. It requires 
demonstration of facts, it believes nothing upon 
any one's authority. 

But very few hours can be given to didactic 
lectures. Actual work in the laboratories, repeat- 
ing the fundamental experiments of biology, is 
the student's main occupation and these he may 
vary as much as his inclination to do so, or his 
genius will prompt. It is not at all excluded that 
the young student may make important modifica- 
tions of existing methods, indeed he may make 
discoveries. He will probably find many facts 
which are not mentioned in the text-books. These 



16 GOLDEN RULES OE SURGERY. 

he will at first believe to be discoveries, because 
he will expect too much from his text-book. But 
before long if his work continues on proper lines, 
and by that I mean continued laboratory work 
with the aid of a teacher who is an investigator 
or researcher, he will soon find out that a text- 
book is a poor, but necessary assistant and ad- 
viser. He will soon find the text-book a most in- 
complete and unreliable authority in scientific ex- 
periment and research. 

In the second two years the student takes up 
the practical departments and nearly all his time 
will be spent in practical courses and in clinics. 
Again he will consult text-books, but he will have 
learned that observation at the bedside is his most 
attractive and most profitable method of study. 
Attending didactic lectures on surgery and medi- 
cine he will find a waste of time, and the brighter 
students will cut these didactic lectures because 
they learn more at home from a good text-book 
than from a lecturer. The reason for this may be 
illustrated by an example. There are doctors who 
are bright glib talkers, but who are very poor 
pathologists and only average surgeons, neverthe- 
less they become professors of surgery, in certain 



THE EDUCATION OF A SURGEON. 17 

medical schools. They teach the principles of sur- 
gery by lecturing before classes to the liking of 
some of their hearers. No one will pretend that 
their lectures will compare at all with Senn's 
beautiful and clear chapters, but all know that the 
lectures are simply taken from Senn's or some 
similar book. They are weak, degenerate, and in- 
complete rehearsals of the text-book. No further 
argument is needed. The student would gain by 
studying the text-book and cutting the lectures. 

The passing of the didactic lecture and of other 
similar methods of misteaching increases pari passu 
with the extension of laboratory courses and dem- 
onstrations. This fact applies to all scientific stud- 
ies and to the arts and crafts that depend on 
science. By other similar "methods of misteach- 
ing" I mean methods of learnino- by rote, such 
as rehearsals, quizzes and parrot-like recitations. 
These methods may help weak brethren to pass 
examinations, but are really unedifying and do not 
educate or instruct, nor do they exercise the intel- 
lect. 

In the university of the future, there .will be 
but little room for lecturers. Lectures, recitations, 
etc., will be relegated to the cheap wild and woolly 



18 GOLDEN RULES OF SURGERY. 

colleges, where eloquence and oratory stand for 
knowledge based on scientific research. 

During the last years the student will do best 
to spend all his time in clinical courses. Hospital 
clinics, obstetrical, insane, orthopedic, in fact daily 
attendance in the wards of all varieties of hospitals 
must engage most of his working hours. Only a 
few hours must be reserved for the reviewing of 
notes by the aid of text-books. The student will 
now be graduated and then comes the most im- 
portant step in the making of a surgeon. He must 
now become attached to the staff of a hospital or 
become assistant to a surgeon who has hospital 
connections, so that he may take part in the daily 
exercise of the science and art of surgery. Ex- 
actly how many years should be thus spent, I 
cannot say. One, two or three years should suf- 
fice to turn out a surgeon who is capable and ready 
to offer his services to the public with a good pros- 
pect of making a useful and a successful diagnos- 
tician and operator.* Before closing this short 



♦Whether or not every man who intends to become a surgeon 
should do general practice for two or three years, will depend on the 
kind of hospital experience he may have enjoyed. We will admit that 
a general practice experience will never hurt a surgeon, but we do not 
deem it necessary in all cases. 



THE EDUCATION OF A SURGEON. 19 

memorandum on the making or evolution of a sur- 
geon let me add a few more reflections. 

I do not believe that any one can become a 
really good surgeon who does not think of him- 
self that he can perform a resection of the pylorus, 
a resection of the three branches of the trigeminus 
or the extirpation of the Gasserian ganglion, near- 
ly or quite as well as any other surgeon in the 
country. 

Neither do I believe greatness can be achieved 
in surgery by any one who does not during the 
first five years of his practice remove some malig- 
nant growths from the face or neck of an unfor- 
tunate fellow, which have been pronounced inop- 
erable by some old and prominent surgeons. It 
follows that in my opinion surgery is not yet a 
complete and perfect art. The technique will con- 
tinue to be improved so that we can extend the 
field of work still farther and make it still safer 
than we have it now. 

Finally let me say that a great surgeon cannot 
be recognized by the public. They have no way 
of judging between a good doctor and a quack or 
between a real surgeon and a mere pretender. The 
cardinal way of judging of a surgeon's work is to 



20 GOLDEN RULES OF SURGERY. 

see it done and to be allowed to see the final results 
of the operations. A great surgeon will therefore 
always be willing to invite colleagues, young ones 
as well as prominent ones, to witness his opera- 
tions, to watch his after-treatment, and to study 
his results. An infallible sign of a great surgeon 
is his willingness" not only to show his results, but 
to teach and demonstrate his methods to students 
and colleagues from any or all quarters of the 
globe.* 

The acquisition of scientific truth for the ben- 
efit of mankind, is made as easy and free as the 
air we breathe, by the great universities. Our 
rich men, by endowing these institutions are doing 
great deeds for their fellow-men of this and of fu- 
ture generations. Great surgeons owe it to man- 
kind to make the. art of surgery as accessible and 
free as is the science. 



*It is a good plan to see different surgeons at work in their own hospitals- 
I know of no place that offers better opportunities to learn than Rochester, 
Minn. I recommend it as a finishing school to all young men ambitious 
to become good surgeons. Use your eyes and your ears while there; keep 
your mouth shut and watch. Not only the Mayo brothers will attract your 
attention, but their whole staff is worthy of careful following. The patholo- 
gists, the anaesthetists, the assistants, as well as all of the specialists, are 
carefully trained and selected men who are capable of teaching and dem- 
onstrating. 



SCIENTIFIC CONTRIBUTIONS. 21 



OX SCIENTIFIC CONTRIBUTIONS TO THE 

LITERATURE OF MEDICINE AND 

SURGERY. 



One of the most effective ways and means of 
becoming rapidly known as a surgeon among one's 
colleagues is the publication of contributions on 
surgical subjects in the contemporary medical 
press. The effectiveness of such work depends 
first upon the character and value of the commu- 
nication and secondly upon the kind and quality 
of the scientific journal that is chosen for the vehi- 
cle of one's writings. 

Unless the essay, article, study or the report 
of interesting cases or of a series of cases, is well 
written and logically and artistically presented it 
will tend rather to injure than to advance the 
young surgeon's progress. It is quite as easy to 
write oneself down as to write oneself up. 



22 GOLDEN RULES OF SURGERY. 

The choice of the subject is not so important 
and no advice can be given about that, beyond say- 
ing that to write about any subject requires the 
writer to have intimate knowledge and experience 
by actual observation, and that to write on any 
subject about which one has only literary or hear- 
say information, drawn from books, is always sui- 
cidal, in fact is silly and childish, and of no value 
beyond that of being an exercise for a schoolboy. 
A communication of that kind fools no one and 
only makes a laughing stock of the, author. 

A contribution to a scientific journal should be 
properly constructed. By way of introduction it 
should show what is known on the subject up to 
the time of writing. The writer should accurately 
give the bibliographical references on what has 
been heretofore published about the matter in 
hand. For this purpose it is not necessary to re- 
fer to what text-books say about the question be- 
cause they can hardly ever be considered as depos- 
itories of scientific communications. They are in 
nearly all cases merely compilations. You will 
always refer only to original memoirs or mono- 
graphs, giving the name of the author first, then 
the subject of his book or article, then the page 



SCIENTIFIC CONTRIBUTIONS. 23 

to which you refer, then the name of the publisher 
and the year in which the publication occurred. 
If there has been more than one edition name the 
one quoted. Let these references follow each 
other in chronological order and let them be accu- 
rate. Never quote a book or an article by any 
author to which you do not actually refer in your 
own contribution. 

After this historical introduction in which you 
show what was known about the subject before 
you made your own investigation, you proceed to 
the main and most important part of your paper. 
This will consist of a detailed account of your own 
labors, giving your observations and the methods 
by which you carried on your researches. Let this 
part of your paper be as long or as short as may 
be necessary to communicate every single fact 
which you have found — this part will contain the 
meat of your work. Let it be accurate, absolutely 
true to nature and let it be illustrated, if figures 
or diagrams will add to the clearness of the 
description or to the lucidity of the demonstration. 
After having completed your scientific description 
and after having given your complete findings, 
the conclusions should follow. 



24 GOLDEN RULES OE SURGERY. 

These must be drawn from the premises or 
facts as you found them. You should then state 
in what your research differs from or corroborates 
the conclusions which were held by scientists in 
the past. If your work has been successful in ad- 
vancing our knowledge a step forward you will 
have the duty and the pleasure of calling attention 
to it. Finally it will be a gracious act on your part 
to express thanks to any teacher or fellow who 
may have rendered you assistance in your re- 
search. Be sure also to mention the institute or 
laboratory or hospital in which your work was 
done. If the work was done in your own labora- 
tory or in your private practice be sure to state this 
to have been the case. 

I desire to impress upon you, that not the mat- 
ter alone but the manner of its presentation will 
largely influence its appreciation by the profes- 
sion. An article or a book which is clumsily writ- 
ten, though it contain somewhat of scientific truth 
may fall flat and be overlooked. An article which 
adds artistic and literary finish to its scientific nu- 
cleus will always - be sure of attracting its full 
quota of notice from the scientific world and will 
receive very favorable notice from the critics and 



SCIENTIFIC CONTRIBUTIONS. 25 

reviewers. You may be fortunate enough to have 
your paper, book, monograph or whatever form 
your contribution may have taken, translated into 
a foreign language or reviewed by contemporary 
scientific or medical journals. These reviews, or 
translations, or perhaps quotations, will be gratify- 
ing to the author exactly in proportion to the 
standing of the scientist who quotes the work. 
And if the quotation be made, together with ap- 
proving and confirming words in the text and by 
a writer personally unknown to the original con- 
tributor, the latter may justly be encouraged to 
further research. 

Remember that to the artistic and literary 
merit of the contribution will be due a large part 
of its success. Therefore don't hurry. In giv- 
ing the anamnesis of a case or a series of cases let 
all data be complete. Give facts, let the reader 
exercise judgment. 

Do not for instance explain away deaths after 
hysterectomy or after pyosalpinx or after appendi- 
citis operations by pneumonia, nephritis or other 
pathological processes. The pneumonia or neph- 
ritis would probably not kill the patient if there 
were no septic infection. Remember that qui 



26 GOLDEN RULES OF SURGERY. 

s J excuse, s' accuse — and that if a patient enters your 
hospital alive and is carried out dead a few days 
after an operation he probably died in consequence 
of the operation. Let it go at that, excuses will 
only make things worse. You did your duty, you 
tried to save life, ultra posse nemo obligator. 

A few words in regard to the choice of the pub- 
lication in which to print your work. If the re- 
search work has been done under a great master 
or at a great laboratory in a university, or in such 
a hospital as for instance Johns Hopkins, of course 
the research will be published in the local bulletin 
or transactions, and at once will enjoy the entree 
into the scientific world. It is manifestly impossi- 
ble to designate by name the most suitable vehicle 
for a future publication. But I will say this, do not 
contribute to any weekly, monthly or quarterly 
publication of which it is clear to every enlightened 
member of our profession that it is merely a com- 
mercial enterprise. In order that I may not be 
misunderstood I say, avoid trade journals or such 
as are owned and published by pharmaceutical or 
patent or proprietary medicine houses. It is pos- 
sible to find a good article in a trade journal, but 
even if a blind chicken does now and then find a 



SCIENTIFIC CONTRIBUTIONS. I / 

grain of wheat, the grain of wheat may be badly 
tainted or even rotten, because of its putrid or un- 
savory environments. An article in one of these 
journals, if it recommends some special prepara- 
tion, will always be regarded with suspicion and 
its author runs the risk of placing himself in an 
oblique light, be he ever so honest. 

If an article is intended to reach only a limited 
number, of a special department, of course you will 
choose a special journal. But if the subject is of 
more general interest, I am giving good advice in 
recommending one of the large weeklies. Both 
the latter and some of the monthlies have been 
recently much improved in regard to value of sci- 
entific reports as well as of editorial work. Amer- 
ican weeklies and monthlies will never equal the 
European until contributors are liberally paid for 
their work,, a thing much to be desired by the en- 
tire medical world. The same is true of profess- 
ors in medical colleges. These latter will always 
be of inferior quality until the teachers are paid 
good living salaries, so that the work of teaching 
in medical colleges becomes more important than 
the following of the practice of medicine and sur- 
gery. Then the professors will have the exalted 



28 GOLDEN RULES OF SURGERY. 

scientific standing in our country that they now 
have in Germany and in France. There is also 
improvement in this direction noticeable within 
the last decade. 

When once the immense wealth of such univer- 
sities as Chicago and Harvard and the endow- 
ment of institutes and of laboratories for scientific 
research, as we see them starting up in Washing- 
ton and New York begin to show results the United 
States will soon be at the head of the world in this 
respect also. Men will come to America, as we in 
the past have gone to Europe for the best opportu- 
nities to do original research. This will come to 
pass during the next twenty-five years and our 
children will enjoy this American Renaissance of the 
Twentieth Century. These institutions will then 
furnish the highest class of archives, quarterlies, 
monthlies or weekly bulletins, in which to publish 
the results of our investigations. 

Before closing this chapter on the subject of 
scientific contributions to literature, I think some 
experiences of my own may be instructive and use- 
ful. My first two publications were embryological 
researches and were printed in the Morphologisches 
Jahresbuch of Leipzig and have been quoted by 



SCIENTIFIC CONTRIBUTIONS. 29 

every author who has written a text-book on this 
subject in any language. This work was done in 
1876. I must say that the prompt acceptation of 
these two memoirs was due to the fact that they 
emanated from the laboratory of Gegenbaur who 
together with Huxley and Haeckee was the lead- 
ing scientific investigator in the field of biology in 
1876. After returning to America to practice sur- 
gery my contributions to its literature have been 
very numerous and I will relate a few of my most 
curious experiences. Soon after my return I was 
consulted by a girl of seventeen years about a 
tumor in her tongue which was rapidly growing 
and completely filling the mouth. It bulged out 
upon the back of the tongue as large as a walnut 
and also bulged the floor of the mouth downwards 
so as to make a round ball below the chin and above 
the hyoid bone. I removed it through a median 
incision. It proved to be a genuine struma or 
goitre situated entirely within the tongue, extend- 
ing from the pyramidal process of the thyroid gland 
to the foramen caecum on the back of the tongue. 
The literature of surgery, searched very thoroughly 
by me, spoke of no tumor originating in the thyro- 
lingual duct. I think indeed that there were few 



30 GOIvDEN RULES OF SURGERY. 

if any surgeons then living who would have known 
what this duct is. I plainly expressed my opinion 
that this tumor (at least twenty similar ones have 
been described since) was developed from epi- 
thelial cells which were, left in the track of the 
thyroid gland as it is developed from the primitive 
epithelium of the pharynx or head gut. It takes 
its descent between the two halves of the tongue 
before they grow completely around it and are 
joined together to form the tongue. This obser- 
vation was published in the St. Louis Medical and 
Surgical Journal It rested there, nothing was said 
about the rather interesting and rare tumor for a 
number of years. About six years after my publi- 
cation Mr. J. Bland Sutton of London, chief sur- 
geon of the Chelsea Hospital, in a very clever work 
on tumors quoted my paper, and agreed with my 
explanation of the origin of the growth. Since 
then this peculiar tumor, now called intra-lingual 
goitre, has been quite frequently seen and written 
about in all civilized countries. But an American 
surgeon must be credited with the neat little scien- 
tific discovery, for which embryological studies 
made at Heidelberg laid the foundation. I can 
assure the young man beginning the study of his 



SCIENTIFIC CONTRIBUTIONS. 31 

profession that few things will give him as much 
satisfaction, as to explain or clear up any phenome- 
non, whether normal or pathological, which has 
hitherto been unexplained or looked upon as a 
problem or a curiosity in science. 

Among my earliest contributions to the art of 
surgery was a paper entitled ideal cholecystoTomy 
— it made a plea for a new method of operation 
and reported a successful case of gallstones treated 
and completely cured by the new operation. Mr. 
Lawson Tait of Birmingham, England, had just 
reported a series of successful cases of cholecysto- 
tomy. His operation strictly followed nature's 
method of discharging gallstones. He attached 
the gallbladder to the abdominal wall by sutures, 
then opened it and evacuated the stones and other 
contents. The hole was allowed to remain open 
and was drained until it closed spontaneously by 
the natural healing process. Nature achieves the 
same result by means of adhesions between the 
gallbladder and the abdominal wall, followed by 
abscess and perforation on the belly wall over the 
region of the gallbladder. This process leads to 
the formation of a biliary fistula which often dis- 
charges for weeks or months or for years. Thus 



32 GOLDEN RULES OE SURGERY. 

Tait's method appeared to me as the natural 
method of cholecystotomy and the method which 
I described seemed to me to deserve the name of 
ideal cholecystotomy because it immediately 
achieved a restoration to health without the form- 
ation of a troublesome fistula. I plainly stated the 
indications for the ideal operation. It can not be 
performed in every case, in fact it can only be per- 
formed in carefully selected cases. But where it 
is indicated it gives ideal results. KoCHER in the 
last edition of his operative surgery speaks of it as 
a most simple and safe operation ! 

At the end of this paper I drew conclusions, one 
of which related to the function of the bile. I set 
up the thesis that the bile must be considered an 
excretion and that it has little or no value as an 
aid to digestion, in fact I believed that there was 
no reliable evidence upon which to base the theory 
that the bile was of any use to the economy. 
This conclusion was based upon observations of 
biliary fistulas. I had seen several of months' and 
one of over twenty years' duration in which all the 
bile was discharged and the subjects of the fistula 
in perfect health. 



SCIENTIFIC CONTRIBUTIONS. 



33 



This publication was made in the St. Louis 
Weekly Medical Review about the year 1883. My 
doctrine went unnoticed in medical literature for 
about twenty years. Lately I have noticed several 
voices in Germany practically maintaining the 
same views about the bile that I published long 
ago. I am fully convinced of the correctness of 
my view and believe that it will prevail as soon as 
the question is properly and carefully investigated 
by a physiologist or a physiological chemist. That 
my doctrine had passed unnoticed is probably due 
to the fact that it was published in a surgical me- 
moir which was not read by physiologists. It has 
thus escaped being noticed for years and the lesson 
which can be drawn from this experience is : Do 
not hide or bury important physiological findings 
in medical or surgical contributions. You can 
thus see that the selection of the proper medium in 
which to publish your contributions may be of 
great importance. 

My communications to surgical literature num- 
ber over one hundred, some of the most important 
being in connection with the subject of appendici- 
tis, the large majority however being case-reports 
and reports of operations suggested by me or done 



34 GOLDEN RULES OE SURGERY. 

for the first time by me. If ever anyone should 
conceive the foolish idea of writing a geographical 
paper on "the progress of surgery west of the 
Mississippi river" the records would show that the 
first operations on the stomach, the extirpation of 
tumors of the brain, the liver, the kidney, the 
intestine, gallbladder, etc., were done by me in 
this territory and also that the first successful oper- 
ation for gunshot wound of the abdominal viscera 
was done by me in this territory. There is only 
one operation which I was the first in 1*he world 
to do successfully and that was the Caesarean sec- 
tion in a case of placenta praevia. I still believe 
that this operation has a future under certain cir- 
cumstances, although I am aware that many ob- 
stetricians are not in favor of it. And still. I will 
say that having to choose between a young well- 
trained surgeon and an old obstetrician to deliver 
a woman with central placenta praevia, I would 
have the young trained surgeon do the classical 
Caesarean section in every instance. It must be 
said here that soon after my arrival in St. Louis in 
1877, the ablest and most useful and busiest sur- 
geon, John T. Hodgen, told me that he had done 
sixteen laparotomies and said he, pointing north- 



SCIENTIFIC CONTRIBUTIONS.. 35 

ward, "I have fifteen tombstones to show for 
them." Another surgeon [perhaps the next in 
prominence] in Missouri, told me that laparotomies 
could not be done successfully in the Mississippi 
valley, as he believed climatic conditions to be un- 
favorable. You will understand that in those times 
the technique of antisepsis was only poorly under- 
stood and asepsis was unknown. I was among the 
first to adopt and teach asepsis and wrote a paper 

OII THE BEST METHOD OE PRACTICAL ANTISEPSIS AND 

ASEPSIS, which did much to popularize the method 
in the United States. We may assume that at the 
present day no surgical operation is done without 
an attempt to be as aseptic as is possible under the 
surrounding conditions. The time is not far away 
when no premeditated operation will be performed 
except in a properly equipped operating room. In 
fact, I think this rule is now generally observed 
where such a place is not too distant or inaccessible. 
Operating rooms which can be made clean, by 
sterilization in some of its forms, are springing up 
even in small country towns. There are no more 
doubting Thomases, the doctrine of surgical clean- 
liness is universal, in fact there are no dissenters. 
Thrice happy the profession of which it can be 



36 GOLDEN RULES OF SURGERY. 

said : it is united, at least upon this the most im- 
portant of its foundations. The modern edifice of 
surgical art rests solidly on this impregnable sci- 
entific base. 



SCIENCE AND SURGERY. 37 



SCIENCE AND SURGERY. 



About ten years ago, a new chancellor was 
called to a western university and after residing in 
the city for a few months, during which time the 
reorganization of the medical department kept him 
busy, he publicly announced that many of the wes- 
tern physicians did not know what science meant. 
This statement caused discussion and some ill-feel- 
ing among physicians, but there is no doubt that 
the chancellor was right. In order to give medical 
students and physicians a clear idea of the meaning 
of science the following thoughts on the subject 
may be here expressed. 

Definitions of science found in most dictionaries 
are : "Science is knowledge" or "science is clas- 
sified knowledge."* While these definitions are per- 



*In this connection permit me to recommend to all physicians who desire 
to rank above the common herd, the study, yes, the intense and diligent 
consideration of the small volume by Herbert Spencer called "First Principles." 
It is the best introduction to science that I know of and can be mastered by 
any one having the qualifications necessary to become a useful surgeon. 



38 GOIvDKN RULES OF SURGERY. 

haps correct, they do not give a complete idea of 
what the term science means or of its scope. 

Science is not only the grandest and most im- 
portant thing on earth, but it deserves our rever- 
ence and culture more than any god that mankind 
has ever worshipped or any idol deified in the past. 
A better definition than the two given is as follows : 
Science is the knowledge of the laws which govern 
this universe. 

Science is still very incomplete because we do 
not know all the rules upon which nature, or if 
you like a plain English word better, upon which 
the world works. In fact we know but a small part 
of the rules or laws of nature, but we are learning 
more of them as science grows. Science is truth, 
anything which is proven untrue can not be scien- 
tific. An author or a text-book may make certain 
statements, which are supposed to be true. The 
author of the text-book believes them to be true, 
but that does not make them true. Science is 
absolutely the opposite of belief, it takes nothing 
for true on anyone's authority or statement. It 
requires proof by demonstration, and the proof and 
demonstration of a statement must be open and 
possible to anyone sufficiently skilled and edu- 



SCIENCE AND SURGERY. 39 

cated to repeat the experiment or demonstration 
upon which the statement is based. When this 
has often been done and the demonstration is 
found flawless by different men independently of 
each other, then a statement or a finding or a dis- 
covery becomes a scientific fact. It does not then 
rest upon anyone's authority, but we say it is a fact 
scientifically established. 

It is clear that science is unfinished as a whole, 
although some minor fields are pretty well worked 
up. It is the opinion of scientific thinkers that 
science never can be completed so that no laws or 
rules upon which the universe works will be un- 
known. We may rejoice that this is true, because 
such a condition would put an end to scientific in- 
vestigation. Research, and in fact mental effort 
of all kinds, would necessarily cease. On the other 
hand, if there were nothing left for belief and faith, 
if there were nothing left of the unknowable, there 
would be no room for religions or creeds. Such 
a condition will never come about, therefore it is 
idle to waste time on its consideration. 

If the definition of science which I have given 
above is correct, then of course science is not only 
the most sublime thing, but also of the utmost 



40 GOLDEN RULES OF SURGERY. 

practical importance, and use to mankind. It is 
the only thing which can possibly lead to an under- 
standing and to an explanation of the phenomena 
which we call life. Our hope of ever knowing ex- 
actly what life is and how it was developed on this 
planet, lies in science. 

There is one other point I wish to raise in this 
connection. A collector of beetles or butterflies 
may be a scientific man. The mere collecting of 
specimens and classifying them does not make him 
so. At best we may consider him a useful helper 
who is gathering valuable material upon which 
some scientific researcher may base scientific ob- 
servations and reflections, which may lead to the 
discovery of an important law of nature or supply 
a missing link somewhere in the chain of scientific 
knowledge. 

Thus we see that in science there may be two 
kinds of laborers of unequal value. The one col- 
lects facts, the other utilizes these facts, classified 
or not, in order to base upon them the laws and 
rules of nature. Both kinds of work deserve our 
help and our approval, though the latter receives 
our admiration in the higher degree, because it 



SCIENCE AND SURGERY. 41 

requires the higher intelligence and reasoning 
power. 

Just as we recognize that our only hope of ever 
knowing the laws of life and rules upon which it 
works rest on science, so do we recognize that 
medicine and surgery rest on science. The solid 
foundation of surgery is science, and our only re- 
gret always has been that the connection between 
practical surgery and exact science is as yet imper- 
fect and indeed surgery is often based on unstable, 
inconstant and variable observations and data. If 
the truth must be told the practice of medicine and 
in a still greater degree the practice of surgery are 
arts. These vocations while seeking for firm scien- 
tific foundation are far from having attained this 
object, at the present time. We know that we are 
becoming more and more successful in the preven- 
tion and cure of disease, as we become better ac- 
quainted with the laws of nature. Our hope of 
still further advance rests upon the progress of 
science and as science discloses more of the laws 
and rules of nature we shall become more scientific 
physicians and surgeons and our fight against dis- 
ease will become more and more successful. 

Remember that science is truth. Much of your 



42 GOLDEN RULES OE SURGERY. 

life should be therefore devoted to the study of 
science. Remember that belief and superstition are 
the opposites of science and tend to keep mankind 
in darkness. Science is light and truth. 

All science is the work of man, and it has been 
developed by the brain functions of man. The cul- 
tivation and expansion of the field of science is 
man's highest and noblest function. Let us re- 
member for instance that the study of the most 
universal and highest questions and problems of 
humanity is Ethics, which also comes under the 
head of science. The clearest work on Ethics* is by 
Herbert Spencer. Remember then that the pur- 
suit of scientific work is man's noblest occupation. 
Scientific workers more than all others deserve 
our sympathy and our aid. Let us accord to them 
honors and rewards without stint. 



'The Data of Ethics. 



BUILDING UP A PRACTICE. 43 



"Else if you would be a man, speak 
what you think to-day in words as hard 
as cannon balls, and to-morrow speak what 
to-morrow thinks in hard words again, 
though it contradict everything you said 
to-day." — Ralph Waldo Emerson. 



ON WAYS AND MEANS OF BUILDING UP 
• A PRACTICE. 



This subject is immense and a large book could 
be written on the many details which may influence 
the career of a physician or surgeon. I can only 
give the general principles, as in fact that is all 
that this little work sets out to do upon any of the 
subjects treated, the author being firmly convinced 
of the truth of the motto Principiis obsta! 

Soon after entering the practice, the question 
of joining a medical society will arise and the only 
advice that can be given is to join. If there are 
several to choose between, as there always will be 



44 GOIvDEN RULES OE SURGERY. 

in large cities, choose the one which is conducted 
on the broadest lines, the least exclusive; it will 
most likely also be the most scientific. Be sure to 
avoid societies which are conducted on the plan of 
debating clubs, where the members are asked to 
write papers on subjects selected by a committee 
for discussion, sometimes called symposiums. It is 
quite possible that meetings of this kind may be 
instructive to the beginner but it is rare indeed that 
a point new to science will be brought out. As 
a rule the men furnishing the parts of the sym- 
posium will read compilations from the available 
literature and at best furnish second-hand inform- 
ation selected by them from text-books or from 
so-called original articles in the journals. You will 
see that an evening spent at this kind of a gather- 
ing scarcely has much to entice a man of scientific 
bent of mind, because he has learned while at the 
university to go to the sources for scientific inform- 
ation and to avoid hearsay evidence. If there be 
no medical society imbued with scientific spirit in 
the city where you live, you will soon learn to 
avoid the meetings, especially if they should prove 
to be devoted to medical politics of a more or less 
personal character. The really good men often 



BUILDING UP A PRACTICE. 45 

shine by their absence from the regular sessions. 
This state of affairs will improve when societies 
will only listen to original communications. 

About joining other social organizations, secret 
or otherwise, with a view to gaining practice, I 
merely say, don't. 

The legitimate way to gain practice is by faith- 
ful performance of duty to your patients and by the 
results which you achieve by your operations and 
treatment. Begin by treating the servants and end 
by treating the mistress. If your work is painstak- 
ing and you take interest in it, your practice must 
grow because nature has wisely arranged matters 
so that of one hundred patients who call upon a 
physician about ninety-five would recover even if 
left without treatment of any kind. It is thus ap- 
parent that you will be successful in the vast ma- 
jority of cases, and your grateful patients will do 
the rest in order to increase your practice. It is 
well to know this fact because it will give the be- 
ginner courage and confidence and prevent him 
from resorting to radical and dangerous measures 
in simple cases. An appreciation of this fact alone, 
will show the beginner that his plain duty lies in 
the conscientious examination and diagnosis of all 



46 GOLDEN RULES OF SURGERY. 

cases, so that he will be sure to separate the dan- 
gerous from the simple ones. This he will find an 
occupation that will fully tax his scientific attain- 
ments. 

In this connection it may be well to say a few 
words on the relation between the legal and the 
medical professions. These come in contact most 
frequently on the occasion of damage suits against 
corporations, most often against railroad compa- 
nies and other common carriers, through expert 
testimony either for the plaintiff or the defendant. 
Here let me say for the solace and encouragement 
of the young medical man that it will be found that 
on medical or surgical topics the most brilliant and 
able lawyer will still be only a layman as compared 
to even a very mediocre surgeon. A knowledge of 
this fact will allay the great nervousness of young 
surgeons appearing in court, but let them not for- 
get that the reverse is true should they venture 
upon the field of law. 

Another occasion upon which these two pro- 
fessions will come together is the malpractice 
suits brought against members of our profession. 
These are in most cases attempts to get money 
from a physician with little or no justification in. 



BUILDING UP A PRACTICE. 47 

fact. It stands to reason that no sane surgeon 
would intentionally injure a patient. Therefore a 
presumption of bad faith lies against the plaintiff 
in these cases. Furthermore, recognizing* the falli- 
bility of all men, even the best, the law does not re- 
quire more than ordinary skill and care on the part 
of the surgeon. From the fact that the result of any 
injury or operation can not be guaranteed by the 
surgeon, in all cases, and that our knowledge is 
incomplete because largely empirical and not al- 
ways based on science, it becomes our plain duty 
to assist fellow-surgeons who may be made de- 
fendants in suits for damages. In testifying before 
juries in these cases let me suggest one bit of ad- 
vice. On all such occasions make yourself under- 
stood by discarding technical terms. For instance, 
do not speak of fracture when you mean a broken 
bone, nor of tibia when the English word shin-bone 
will convey your exact meaning. Many cases are 
lost because the minds of the jury are befuddled by 
the expert witnesses who use terms that are unin- 
telligible to the jury. In a damage suit tried re- 
cently one of the experts for the defendant dis- 
qualified himself from ever testifying in behalf of 
another fellow-surgeon and also vitiated his testi- 



48 GOLDEN RULES OF SURGERY. 

mony in the case at bar in which a surgeon was 
sued for malpractice. It was a case of crushed 
knee with fracture of the femur near the joint, dirt 
from the street having entered the wound in which 
the surgeon made a primary resection resulting in 
a flail joint. The suit was for $20,000. The plain- 
tiff claimed that the operation of resection was too 
radical and a more conservative method should 
have been followed. During his cross-examination 
the expert said that he would under no circum- 
stances testify against a brother physician. This, 
of course, was going too far in a good cause, and 
I want to call attention to the great danger of over 
zealousness on the witness stand, because it defeats 
its own object, as it did in this case. The record will 
forever preclude this surgeon from aiding a brother 
who may be held up by a designing and unscrupu- 
lous plaintiff. Therefore be calm and do not over- 
shoot the mark. In recent years insurance com- 
panies against possible damages from malpractice 
suits have sprung up in the United States and I 
am so favorably impressed with them that I most 
cordially recommend them to all colleagues, though 
I never had the advertisement of being sued for 
malpractice. 



BUILDING UP A PRACTICE. 49 

Finally, avoid frictions and jealousies with col- 
leagues, keep out of cliques, remember that strong 
men can stand alone, weak ones must lean on each 
other. And if you are persecuted by jealous rivals, 
cheer up ! Men do not combine against insignifi- 
cant foes, or train parks of artillery against fleas. 
"The most clubs are found under the best apple 
trees," Abraham Lincoln told Mr. Seward on a 
memorable occasion. So, I say to you, keep right 
on with your work. If it is good work, lies will not 
retard your success. 



50 GOLDEN RUI^S OF SURGERY. 



ABOUT FEES. 



Surgical services have no fixed cost; they are 
without value in that they are invaluable. As a 
general proposition it is true that large fees have 
a tendency to elevate the profession in the eyes of 
the business world. This matter of fees has noth- 
ing whatever to do with the scientific attainments 
of a physician or surgeon. 

Recently the medical press has editorially and 
otherwise given much space to 'the subject, of the 
division of fees or to the paying of percentage or 
commission to men who refer or bring cases to 
eminent colleagues and specialists. 

A maudlin, and ill-advised stand has # been 
taken by some in favor of the practice ; the argu- 
ment being that the poor general practitioner is 
underpaid for his work, gets a mere pittance from 
his patients, and often nothing at all. This argu- 



ABOUT FEES. 51 

ment falls because of the fact that no man is obliged 
to render valuable services free of charge. If he 
does not charge and collect, the presumption is that 
the services in his own estimation are cheap or 
without value, always supposing the patient able 
to pay. 

Where patients and their friends and relatives 
are unable to pay, charity should always be exer- 
cised to the utmost by our profession. 

Where the ability to pay exists good fees should 
be insisted upon. The fee should be in proportion 
to the service rendered and its value to the patient. 

The practice of paying commissions is vile, 
mean, dishonest. Not only the man who receives 
the commission is degraded but also the man who 
grants it. 

I favor a definite understanding between sur- 
geon and patient before the services are rendered. 

Beware of becoming a commis voyageur or 
drummer. Don't often attend little county or dis- 
trict societies — let the country doctors attend the 
big meetings. It will be more profitable to them. 



52 GOLDEN RULES OE SURGERY. 



"The objects I have had in view are 
briefly these — to promote the increase of 
natural knowledge and forward the appli- 
cation of scientific method to all problems 
of life — in the conviction that there is no 
alleviation for the sufferings of mankind 
except veracity of thought and action and 
the resolute facing of the world as it is 
when the garment of make-believe by 
which pious hands have hidden its uglier 
features is stripped off." — Thos. H. Huxley. 



OFF WITH THE CLOAK OF SUPERSTITION 

WHICH STILL CLINGS TO THE 

SHOULDERS OF THE 

PROFESSION! 



To see sumptuous edifice upon sumptuous edi- 
fice going up to new cults which cater to the eter- 
nal craving for the mystic that lies in the heart of 
man, one might suppose that the tide of supersti- 
tion was rising. What does the progress of science, 
what do the researches made in all exact branches 



OFF WITH THE CLOAK OF SUPERSTITION. 53 

count for, we ask ourselves, when thousands flock 
to the abodes of fakirs, charlatans, divine healers 
and others of that ilk, to whom anatomy, physi- 
ology, and elementary disciplines of medicine are 
a book sealed with seven seals ; not to speak of 
diagnosis and the difficult art of surgery which 
can only be acquired by men particularly gifted in 
the first place and most particularly trained in the 
second. 

I am afraid that even our own profession does 
not do all it could to help "ccrascr I'iufamc" as 
that enlightened Eighteenth Century philosopher, 
the astute and persistent enemy of supersition, 
Voltaire, phrased it. Most of his letters to Freder- 
ick the Great of Prussia, and there exists a volum- 
inous correspondence between the two, ended with 
the war cry, "Bcrasez Vinfame" (Crush the infam- 
ous), with which adjective he designated super- 
stition, or often by way of abbreviation with 
only the cabbalistic-looking word, "Ecrlinf," made 
up of the first syllable of ecrasez and the first of 
Vinfame- Voltaire, dead more than a hundred 
years, understood better than many of our own 
latter-day practitioners of medicine that the only 
way to wipe out superstition is through enlighten- 



54 GOLDEN RULKS OF SURGERY. 

ing the people. If he could this moment be cited 
back from the dead and personally conducted 
through the United States with its many inventions 
to make things go, such as steam transportation 
and steam navigation, electric lighting, telephones, 
steel-ribbed sky-scrapers and whatever other ap- 
purtenances human ingenuity applied to the con- 
quest of nature has devised, he might be for an in- 
stant astounded. But would not a sardonic smile 
play about his thin expressive lips as soon as he dis- 
covered the vogue of Mrs. Eddy's medical religion? 
And when he beheld the temples erected to this 
new revelation, "Ecrlinf !" he would mutter and hie 
himself back into the shadowy region whence he 
came, convinced that his work was far from com- 
pleted, though seemingly a race of giants had been 
on earth since his demise, which had arrayed the 
old forces of nature and new ones hardly dreamed 
of in his time, to be their slaves and do their bid- 
ding. 

I am afraid the medical profession is not united 
in spreading enlightenment and crushing the 
hydra-headed serpent of superstition. It is so diffi- 
cult to make earnest and persistent researches, 
deep and long-continued studies in science, it is so 



OFF WITH THE) CLOAK OF SUPERSTITION. 00 

easy to invent a plausible and high-sounding theory 
about the mysterious workings of nature. It is so 
difficult and a little depressing to acknowledge that 
there is much as yet unexplained and inexplicable 
about the laws of disease and health, it is so easy 
to make large and sweeping statements and claims 
which are not susceptible of proof or disproof by 
the untaught laity. There is, moreover, even among 
the well-educated public a marked disposition to 
exaggerate the powers of the diagnostician, the 
surgeon and even the plain practitioner, to invest 
him with a power and knowledge that savors of 
the supernatural. Many a heart is not stout enough 
and honest enough to resist the blandishments of 
vanity, the whisperings of self-interest to trade 
upon the stupidity of the public which fairly clam- 
ors to be deceived. 

One of the greatest feats of understanding ever 
accomplished by human intellect is the separation 
of the knowable from the unknowable. It is clear 
to all men that if a thing is unknowable, a question 
unanswerable, it is a waste of time to occupy one- 
self with it. Our energies and the time allotted us 
on earth would better be put to a wiser use. Kant 
and various German philosophers first elucidated 



56 GOLDEN RULES OE SURGERY. 

this question of the knowable and unknowable. 
But you of the English tongue will do best by- 
reading Herbert Spencer's clear and convincing 
exposition of the bounds of human thought. The 
question of the immortality of the soul is an in- 
stance of the unknowable. It is and will always be 
a matter of faith and not of science and has nothing 
whatever to do with a man's ability and achieve- 
ments in an exact science. I would therefore 
counsel you to avoid discussion of such subjects. 
It is worse than useless, may make you enemies, 
at any rate it can in no wise profit you. 

It is the province of the clergyman to guide the 
public in matters of belief. To him you may leave 
the spiritual welfare of mankind. To him also may 
be left the attitude and the apparel of the Reverend 
and the Most Reverend, which is of a piece and in 
keeping with his assumed knowledge of the un- 
knowable. You who concern yourselves with the 
knowable have no business to bear yourselves or 
clothe yourselves with any mental or physical garb 
which would remind your fellow-citizens of the 
time when priest and physician were combined in 
one and the same individual. The long beard 
which was formerly an attribute of the medical 



OFF WITH THE CLOAK OF SUPERSTITION. 57 

man, thanks to antiseptics has gone out of fashion, 
but some of the older men of our profession still 
cling to the long frock-coat and tall hat, as exter- 
nal signs of their calling. I advise young men not 
to resort to any external expression of the dignity 
of their profession. The dignity lies in character, 
in the conscientiousness, ability and success with 
which a man handles his cases, not in any trick of 
the voice, gravity of the countenance, bearing of 
r the body — or meaner still in the garb assumed. 
Leave all such affectations, accessories and stage- 
properties to the quack, the mountebank and the 
impostor. They are reminders, to be shunned and 
abhorred, of the time when the priest-physician 
was inevitably also a charlatan and hypocrite. To 
Josh Billings the translation of this sentiment into 
the breezy and unabashed speech of our wide and 
free and glorious West is attributed. "Dignity," 
he is credited with saying, "is no more a sign of 
wisdom than a paper collar is of a clean shirt." 

Therefore, off with the cloak, whether it be as- 
sumed to indicate dignity or to hide ignorance. It 
is a hollow pretense, a husk likely to be empty of 
anything but arrogance and hypocrisy. Cast it 
aside as unworthy of an honest vocation. None 



58 GOLDEN RULES OF SURGERY. 

have a better right to walk upright and look men 
straight in the face than those of our profession. 
But let us be rooted in science, and based on noth- 
ing but science. We must disdain to be shrouded 
in mystery, scorn to let the ignorant impute to us 
supernatural attributes. Our vocation is the most 
honorable and the most beneficial to mankind, so 
long as we keep it free from the pretense to extra- 
ordinary powers. We need no veil to hide mystic 
rites, we should wear no ample cloak to drape our 
forms with dignity as did those augurs of old, of 
whom it is told that they stuck their tongues in 
their cheeks as they passed each other in the street 
in mockery of the ignorant who revered their sup- 
posed occult powers and imputed relations to the 
supernatural. Down with the cloak and up with 
the banner of science which invites the light, ever 
more and stronger light upon our labors, that all 
may see and understand what we can do and what 
to us is impossible ! 



GENERAL CONSIDERATIONS. 59 



GOLDEN RULES OF SURGERY, 
GENERAL CONSIDERATIONS. 



Asepsis is the first essential condition of suc- 
cessful surgery; a close second is Rest. 

Remember that under the influence of rest re- 
generation and repair of diseased or injured tis- 
sues takes place most rapidly and is free from pain. 

Asepsis and Rest are the two conditions under- 
lying the healing process. The art of surgery con- 
sists mainly in the application of these two funda- 
mental principles in the most appropriate manner 
to special cases. By their faultless application so- 
called inflammation is avoided. 

The most successful surgeon is he who can ap- 
ply this rule effectively in his practice during and 
after his operations. It is self-evident that without 
asepsis there can be no rest. 

There are two kinds of rest — mechanical and 
physiological. 



60 GOLDEN RULES OF SURGERY, 

The application of mechanical rest is a matter 
of skill and experience and depends largely upon 
the personal ingenuity of the surgeon. 

The most important form of physiological* un- 
rest is caused by the entrance of infectious material 
into the tissues. It is the form of unrest we try 
to avoid by asepsis. It was known as inflamma- 
tion long before its cause was discovered to be in- 
fection. 

This form of unrest is quickly followed by pain, 
swelling, fever, etc., whereas the lack of mechani- 
cal rest is not usually followed by these symptoms 
until it also produces a condition which I have 
called tissue-unrest. There is apparently a dif- 
ference then between tissue-unrest produced by 
infection and tissue-unrest produced by mechanical 
causes. If I may be permitted to guess what the 
difference is, I will say that mechanical insults do 
not cause fever unless they cause necrosis of tis- 
sue, perhaps only the death of a limited portion 
of tissue which being absorbed causes some fever 
and pain. See page 137. 



*The proper term would be pathological-unrest, but the word that fully 
expresses my meaning is the new word tissuetmrest. See "Away with In- 
flammation, etc.," page 138. 



GENERAL CONSIDERATIONS. 



6f 



For example in a simple fracture of the arm 
there can be no infection, because there is no les- 
ion of the skin. There is pain until mechanical rest 
is given to the injured parts. 

There is pain until both kinds of rest are given 
to the injured parts by reduction, and a proper 
splint or bandage is applied to maintain it. 

In another case, for instance in a carbuncle or 
anthrax-pustule, where septic material has found 
entry into the tissues, there will be pain until by 
an incision or by pointing the noxious matter is 
discharged. Thus we see that a knife may be 

THE DIRECT MEANS OF GIVING REST. 

The surgeon who has his asepsis all right will 
find his time most usefully occupied in devising 
ways and means of achieving rest to the tissues 
that have been disturbed by his operations. He 
will find himself handling the tissues with the ut- 
most care and tenderness of touch, so as to avoid 
mechanical disturbance and irritation. He will be- 
come more gentle in his operative manipulations, 
as he realizes the dangers of creating increased 
pain by rough handling of tissues. One of the 
main objects of the dressings we put on wounds is 
to give the parts as much rest as possible. 



62 GOLDEN RULES OF SURGERY. 

That pain is absent when we can give rest to 
diseased parts and, that pain can be relieved by 
rest, are two of the most important rules of prac- 
tice a surgeon must learn. 

I hope that no one will so misunderstand the 
golden rules about the influence of rest in regenera- 
tion and healing of diseased and injured tissue as 
to give opium or morphine to produce rest. 

That would be to change the most important 
and fundamental rule of surgery into the most dan- 
gerous and harmful practice. 

Rest secured by means of poison injected into 
the human organism is apt to do more harm than 
good. I am convinced that the administration of 
such drugs as belladonna, cocaine, morphine, 
strychnine, veratrum, digitalis and many oth- 
er poisons to human beings, by even our most 
highly educated physicians, is wrong. We know 
but little of their real effects upon the healthy ani- 
mal. How much less do we know of their force 
and effect on the weakened organism of our pa- 
tients? 

I am of the opinion that the physician who 



GENERAL CONSIDERATIONS. 63 

uses these drugs upon his patients overestimates 
his own knowledge of the action of drugs, and 
nearly always has been misguided by his blind 
trust in the text-books on materia medica. I wish 
to go on record as being opposed to the general 
use of drugs in the treatment of disease. 

The idea that a doctor's main business is to 
write prescriptions must be abolished among the 
public. 

The scientific physician cannot but feel the deep 
degradation of being asked for a prescription with- 
out first having a chance to make an examination 
and diagnosis. The public must be trained to pay 
for the latter and not for the former. If we reach 
this appreciation of our work from the public, as 
many of us have done, there will be but little left 
for the prescription doctor and the ignorant quack 
to prey upon. 

Remember to talk and to act in favor of the 
public schools and state universities whenever an 
opportunity presents itself. Do the same in favor 
of the taxation of churches and all kinds of property 
held in their name, though they be hospitals. If this 
is not done soon these institutions held by the dead 
hand (la main morte) will be so rich by escaping 



64 GOLDEN RULES OF SURGERY. 

the taxes, that they will wield more power than the 
trusts do now. Any good actuary or banker can 
figure out this problem for you. 

The reason why some American surgeons ex- 
cel European surgeons, who would seem to have 
the better opportunities for study is because their 
knowledge is autoptical. The European bases his 
knowledge and judgment largely on autopsies. 
During the past year the Mayo brothers removed 
one thousand and twenty-one appendices from liv- 
ing patients. Incidentally let me remark that 
eight of this number died. I cite this experience 
as an instance of autoptical pathological study. 

It is my opinion that in conjunction with the 
microscopical examination of the appendices the 
autoptical knowledge and judgment of the process 
under consideration will be much more valuable 
than the autopsical knowledge of the Germans, if I 
may be permitted to coin a word. The same is 
true of stomach, gallbladder and many other le- 
sions that are treated surgically in our day. 

Therefore let young men miss no opportunity 
to see operations and to examine the diseased tis- 
sues or organs. The autoptical view will always 
be more instructive to the young surgeon than the 
autopsical. 



GENERAL RULES 0E PRACTICE. 65 



SOME GENERAL RULES OF PRACTICE. 



Beware of diagnosing any disease of which you 
have recently read, or have lately seen or heard of. 

Amputation of a finger or toe is minor surgery, 
of the thigh is major. Who can draw the dividing 
line ? 

Never confine old people to bed for long [on 
account of the tendency to fatty and dilated heart 
and hypostatic congestion of the lungs]. 

Never use a hypodermic syringe in a patient in 
the secondary stage of syphilis, or if you do, re- 
member thoroughly to ascepticise it after use. 

Never permit a wet-nurse to be employed with- 
out examining into her history and state of health. 



66 GOLDEN RULES OE SURGERY. 

Never permit a healthy wet-nurse to suckle a 
syphilitic child, or a child of syphilitic parents. 

Never be hasty in suspecting "malingering" in 
any disease, certainly never in head injuries. 

Remember that if a man has been taking a 
quart of whiskey per day for years, and you take 
it away from him suddenly during an acute attack 
of fever or pneumonia, he will probably die. 

Never neglect to bandage carefully the entire 
limb, if you have encircled it at any one point to 
keep up pressure upon a wound. 

In the broken down, avoid cathartics, depriva- 
tion of nourishment, and loss of blood by incision. 

Remember that drunkards, children and pa- 
tients with jaundice or splenic disease, bear loss of 
blood very badly. 

Be careful of opium in delirium tremens when 
the pupils are contracted. 

Never examine any female per vaginam under 
any circumstances without having first obtained 
her consent, nor without the presence of one or 
more reliable witnesses. 



GENERAL RULES OE PRACTICE. 07 

Never examine any female prisoner per vagi- 
nam without her consent, without cautioning her 
that the examination will be taken down in evi- 
dence, and without a female companion being 
present. 

Remember that in all organic lesions of any part 
of the body which the patient can himself see or 
feel there is always a psychical element. This 
feature of the case may require treatment. The 
removal of the growth or deformity is the best and 
the most radical cure. But when for some reason 
surgical operation is impossible, much relief can be 
given by suggestion and persuasion carried out by 
a clever physician. In many cases a change of en- 
vironment, by travel, or weeks spent in a sanita- 
rium or an institution, aided by massage, gymnas- 
tics or some similar therapeutic method may be 
of great benefit. 

Remember that in most aseptic operations that 
we can do, several thousand bacteria will get 
into the wound. These will be nicely eliminated 
or made harmless if the tissues have been gently 
handled by the operator and are healthy. 

Rubber gloves are of use if the operator must 



68 GOLDEN RULES OF SURGERY. 

do an aseptic operation after a septic one. They 
are not the boon that we expected them to be. I 
have nearly abandoned them after many trials. In 
my case so much fluid or sweat accumulates in 
them in a short time that a puncture will let out a 
half dram or more of fluid containing many bac- 
teria, especially if I have been obliged to use much 
force in tying ligatures. There are other objections 
to gloves. 

Death following a minor operation, in which it 
was least expected, is among the most horrible ac- 
cidents that can befall a surgeon. These' deaths 
are due to septic infection in about ninety-nine 
cases out of one hundred. They follow an infec- 
tion, and death usually ensues in from two to thirty 
days after the operation. In these cases the error 
in the aseptic arrangements nearly always escapes 
detection. It is found impossible to locate a fault 
or mistake with any of the nurses, assistants or 
with the chief operator. The same staff may have 
done several successful operations of much greater 
importance in the same room, on the same day. 
In these cases we are reminded that our antiseptic 
precautions, or our asepsis, is not yet infallible or 
reliable. When a minor operation, such as for in- 
stance an operation for piles, a perineorrhaphy, or 



GENERAL RULES OF PRACTICE. 69 

a cosmetic operation upon the face, is followed by 
erysipelas or some other form of sepsis and ends 
in death, the physician and surgeon are in a most 
lamentable position. The best plan in this situation 
is to admit that the cause or point of entrance of 
the septic poison is unknown and to inform the rel- 
atives and friends that deaths of this kind are very 
rare, but unavoidable. I do not think that acci- 
dents of this kind occur more frequently than fa- 
talities during anaesthesia and they are growing 
more and more rare as our technique is made more 
perfect. (See Anaesthetics, page 75.) 

The policy of charging these deaths to heart dis- 
ease or to some obscure form of nerve disturbance 
is a bad one and should receive the quietus that 
we have put upon other forms of deception which 
were formerly sanctioned, because of our lack of 
scientific pathology. Nothing but the most sincere 
sympathy ought to be extended to a surgeon to 
whom this kind of ah accident happens. No kind 
of blame can lie against the hospital or the surgeon 
to whom this accident happens during a long and 
successful career. On the other hand, punishment 
can not be too severely visited upon an institution 
or a man whose work shows a regular, long contin- 



70 GOLDEN RULES OE SURGERY. 

tied death-rate which is much above the usual av- 
erage. 

Under the protecting aegis of antisepsis and 
asepsis, fools rush in with seeming impunity — but 
only with seeming impunity I say — and operate 
where sages would hesitate. 

In the past thirty years I have observed hospit- 
als, sanitariums and similar institutions, and their 
surgeons come and go. 

Those whose work is followed constantly by a 
high mortality never last very long. Such insti- 
tutes very soon go into liquidation; bad surgeons 
lose their practice or retire to some less strenuous 
department of medicine or withdraw from the pro- 
fession entirely.* The fact is that surgery unless 
successful, loses its charm, and unsuccessful op- 
erators abandon the field for the relief of their own 
conscience which will not be quiet until they have 
either improved their surgical methods, or failing 
in that, have given up the practice of surgery. 
There is a vestige of truth in the old saying that 
surgeons are born, not made — those that are born 



*A very salutary effect is exercised on bad or unsuccessful operators and 
their hospitals by the nurses and hospital employees. These latter soon notice 
an abnormally high mortality following the work of some men as compared 
to that of others, and this truth will come out. 



GENERAL, RULES OF PRACTICE. <± 

with the proper instincts last longest, while those 
that come into the fold at the eleventh hour rarely 
seem to grow warm and enthusiastic in the work. 
Those also who enter the profession with an eye 
to the main chance, whose first object is to make 
money out of surgery, seem to be easily diverted 
into other lines of work and are not usually among 
the most successful. An enthusiasm which will 
lead the young surgeon to perform the most diffi- 
cult and dangerous operations free of charge seems 
essential in the character that goes to make a great 
surgeon. Another thing that seems to character- 
ize all great and good surgeons is their delight in 
teaching young men the art of surgery so that they 
may leave behind them a number of pupils or as- 
sistants to whom they can point with satisfaction 
as to their spiritual progeny. 

If this should lead, as it sometimes does, notably 
in the cases of v. Langenbeck and Billroth, to 
a general recognition of their pupils as the leading 
surgeons of their generation, the ambition and the 
glory of such teachers of surgery will have reached 
the summit. 

There is great danger of overlooking the hu- 
man or philanthropic side of a case in the enthu- 



il GOLDEN RULES OF SURGERY. 

siasm which scientific research arouses in a student 
of biology. This science, being the basis of modern 
medicine, is so interesting and such an enticing 
field for research that to an intense worker a case 
may appear to be merely an object upon which 
to make scientific observations. Beware of this 
error and remember that to a patient there is but 
one object in the practice of medicine, and that is 
to make him well, to cure his ills. 

Remember the difference between a case and a 
patient. 

Remember to treat the patient as well as his 
disease. 

The scientific study and diagnosis of a case is 

ONE THING, THE TREATMENT OF A PATIENT ANOTHER. 

Both functions are demanded of a physician, and 
the ability to fill them both well when combined in 
one man has made the great masters in our pro- 
fession. 

I do not desire to be understood as exacting all 
scientific requirements of one man, in our times. 
Let the case be examined and diagnosed scientifi- 
cally by expert specialists. Then let the surgeon 
take the case and operate. 



MINOR SURGERY. 73 



CAN MINOR SURGERY BE DONE IN THE 
OFFICE? 



There is no doubt that many surgeons are do- 
ing minor surgery in their offices. Nothing can be 
said against this practice if the office is as well 
equipped for the purpose as is a modern operating 
room in a hospital, except that the patient will 
always be subject to the dangers of a transporta- 
tion to his home. If these dangers seem to be a 
negligeable quantity there can be but little objec- 
tion. And still for all but certain specialists the 
practice is not to be recommended. I think that 
such operations as currettement or the ablation of 
haemorrhoids or the dilatation of urethral strictures 
should be done under anaesthesia and in a hospital 
and neither at the home of the patient nor at the 
surgeon's office. The dangers and accidents which 
may follow an anaesthesia, either local or general, 
should not.be incurred except at a hospital. Be- 



74 GOLDEN RULES OF SURGERY. 

sides, I am sure that an office can hardly be sur- 
rounded by all aseptic precautions as securely as 
an operating room in a hospital. Another reason 
for condemning office operations is" the fact that 
the failure or success of office operations will de- 
pend upon the preparation previous to the opera- 
tion, which is always necessary; and this can be 
given much more fittingly in a hospital than else- 
where. Another weighty argument against office 
operations is that we never know exactly what pa- 
tients will suffer from shock after minor operations, 
but we do know that the treatment of this condi- 
tion can become very protracted and may require 
the most painstaking attention, severely taxing the 
trained attendants of a well equipped hospital in 
some cases. Therefore I can not advise the office 
treatment of minor surgical cases, in other words, 
I do not favor the performance of operations re- 
quiring anaesthesia in the office. The after-treat- 
ment and the changing of dressings in which anaes- 
thesia is not required may be done in a well fur- 
nished office, although even for this purpose the 
dressing room of a hospital is the safest and the 
most preferable place. 



ANAESTHETICS. < 



ANAESTHETICS. 



Never administer an anaesthetic except in the 
presence of a third person, or allow it to be ad- 
ministered in your own house. Remember to have 
all false teeth removed, to secure an empty stom- 
ach, and a horizontal position, to release all tight 
clothing, and to use an absolutely pure drug. 

The urine, heart and lungs should be examined 
the day before the operation, by the anaesthetist. 

Remember that sudden failure of respiration 
sometimes occurs in cases needing tracheotomy. 
Therefore, give as little of the anaesthetic as possi- 
ble — do what is indicated to supply the air or oxy- 
gen which is wanted. 

Never forget that while enough of the anaes- 
thetic should be given to ensure complete insensi- 
bility before the surgeon commences and while he 
is operating, care should be taken that the patient 



76 GOIvDEN RULES OF SURGERY. 

has no more of the anaesthetic than is absolutely 
needed. This rule also applies to subcutaneous or 
intraspinal injection of cocaine. There are deaths 
reported from intra-urethral injection of small 
doses of cocaine. 

Never forget that deaths from anaesthetics are 
most frequent in operations for trivial troubles. I 
am one of those who believe that fright greatly 
increases the danger. 

Deaths during anaesthesia are unavoidable. 
Fortunately they are very rare. I have made a 
most careful analysis of all existing statistics and 
I think that the mortality of anaesthesia of all 
kinds for surgical purposes is in round numbers 1 
in 4000. 



WARNINGS AND CAUTIONS. 77 



WARNINGS AND CAUTIONS. 



Remember never to make promises of any kind, 
and particularly as to the result and the exact 
length of time it will require to get a cure, because 
a wound may suppurate- in spite of all our precau- 
tions. 

Never forget to warn your patient that a Colles' 
fracture and other bone or joint injuries, even 
when treated with the greatest care, leave some 
deformity. 

Never forget to warn a patient with fracture 
of the patella, that the fragments tend to separate. 

Always warn your patient that there may be 
loss of power of deltoid after dislocation of shoul- 
der when much pain has been experienced [pain is 
the evidence that the nerves have been pressed 
upon, or greatly stretched]. 



78 . GOLDEN RULES OF SURGERY. 

Always warn the patient or his friends of the 
possibility of suspension of growth in the length 
of the bone, after the injury to an epiphyseal carti- 
lage. 

Never forget to warn the parents of a hare-lip 
patient that one operation is often inadequate. 

Never forget to warn your patient that the 
loose cutaneous anal tags always swell temporarily 
after an operation for piles, or he may suppose 
you have overlooked them, and that the operation 
is incomplete. 

Never forget to warn your patient that a Mei- 
bomian cyst fills with blood after being scooped 
out, or he will think the operation has been per- 
formed in a slovenly manner. 

Always warn the patient's friends that fluid tak- 
en by the mouth may run out through a trach- 
eotomy wound for the first few hours, and that 
this is not due to a wound of the gullet. 

Always make your patient with angular curv- 
ature understand that no visible improvement in 
the deformity can be expected from the use of the 



WARNINGS AND CAUTIONS. 79 

supports, but that they are ordered to relieve pain, 
and prevent further displacement. 

Always warn your elderly patients that a contu- 
sion of the hip sometimes causes shortening, es- 
pecially if the case be the subject of rheumatic 
arthritis. 

Remember that consent is necessary to make an 
operation legally permissible. The question from 
whom consent must be obtained is not clear in all 
cases. In operations upon a wife for instance, 
some courts have held that the husband's consent 
is necessary. 

A surgeon must keep within the strict scope of 
authority expressly given him, or he must be able 
to show that he had permission to do whatever 
might be found necessary during the procedure. 



80 GOLDEN RULES OF SURGERY. 



ABDOMEN. 



Always avoid purgatives in treating a patient 
who has swallowed a foreign body. Give opium 
and constipating food — boiled eggs, cheese, pud- 
ding, potatoes, etc. ; a few days later you may 
purge. 

Remember that opium masks the symptoms of 
strangulated gut, appendicitis, and peritonitis, and 
may deceive both surgeon and patient in gauging 
the urgency of the case. 

It is a good rule to give a purge when tempted 
to give opium in obscure abdominal pain. The 
purge cleans and clears, the opium obscures and 
obstructs. 

Remember it is the atony of long continued ob- 
struction which causes the mortality of colotomy, 
not the operation itself. Long continued disten- 



ABDOMEN. 81 

tion is accompanied by paralysis of the coats and 
vice versa. 

Never procrastinate in strangulated hernia. Re- 
duce by taxis or operation at the earliest possible 
moment. 

Remember that about one half of all strangula- 
ted hernias which have resisted taxis without re- 
laxation will slip back under complete relaxation 
brought about by an anaesthetic. 

It is a good rule to wash out the stomach and 
also the colon before proceeding to reduce by 
taxis or to operate under anaesthesia, when there 
has been much vomiting or where the hernia is of 
large size. 

Remember that the abdomen has become the 
favorite field of the operators who don't know 
much about anatomy. It is so easy to remove cer 
tain little superfluous or troublesome organs. Be- 
ware of the pelvic surgeon "limited." 

Do not forget that "belly-ache" in a child may 
indicate the passage of uric acid gravel from one 
or other kidney. 



82 GOIX>EN RULES OF SURGERY. 

Do not omit to examine the spine of a child 
who has a grunting respiration or a frequent 
belly-ache continuing at intervals for a long period. 
These symptoms are both significant in Pott's dis- 
ease. 

Never give a positive diagnosis of an obscure 
abdominal tumor until you have examined the 
patient after purgation and under anaesthesia. 

The removal of abdominal tumors is the sur- 
gery which is most showy and satisfactory in its 
results. It is also most interesting, because no 
two tumors are exactly alike. Malignancy is found 
only in about ten per cent, of the cases. 

Remember that very large solid abdominal tu- 
mors in children are very frequently either renal 
or retroperitoneal sarcoma. 

Uterine myoma and ovarian cysts are the sur- 
geon's delight, but occasionally one of these tumors 
may tax the resources of the operator to the ut- 
most. I have done resection of intestine and trans- 
plantation of one ureter while removing such tu- 
mors. 



ABDOMEN. bo 

Remember that an inflamed appendix is the 
most frequent cause of obscure suppurative peri- 
tonitis. 

Do not diagnose every pain in the position of 
the appendix as appendicitis. In women salpin- 
gitis is about as frequent as stricture in men, 

Remember there is such a disease as descend- 
ing renal calculus on the right side, and it simu- 
lates appendicitis. 

In kicks or blows upon the abdomen by a 
blunt object, for instance a horse's hoof, there may 
be no external sign of injury, but the intestines 
may be ruptured. Lose no time in opening and 
draining. 

Do not trust the temperature too much in real 
appendicitis. Watch the pulse to judge if suppu- 
ration is commencing. 

Remember, a rising pulse rate of 110 after free 
action of the bowels and exclusion of typhoid, gen- 
erally indicates necessity for surgical intervention. 



84 GOLDEN RULES OE SURGERY. 

Never probe* any punctured wound in the ab- 
dominal or thoracic wall. This rule does not ap- 
ply when the surgeon is prepared and ready to do 
an aseptic operation. 

Always relax the abdominal wall after sutur- 
ing a wound of the parietes. 

Never close any wound of the abdominal wall 
till all haemorrhage has ceased. 

Never under any circumstances apply pressure 
to a wound of the abdominal wall to arrest haem- 
orrhage. 

There is little or no danger of perforation of 
an intestinal ulcer by giving a purge. There is al- 
ways a negative pressure inside the small intestine. 
If this were not true, no method of suture would 
hold. 

Never mind increasing a superficial wound of 
the abdomen in order to remove a tumor or to 
secure a bleeding point. 

The best method of giving rest to the over- 



*"A probe in the hands of a dirty or rough surgeon is like a loaded pistol 
in the paw of a monkey." 



ABDOMEN. 85 

worked or diseased intestines is to clean them out 
by castor oil or salines and not by opium. 

Never neglect to pass your finger fairly through 
the wound when replacing protruding viscera, in 
order to make sure that the reduction has been 
complete; and be careful never to push the bowel 
into an interstice between the muscles or into sub- 
peritoneal tissue whilst reducing. 

Never ligature a large piece of omentum en 
masse. Do it piecemeal, for the constricted edge 
of the apron of omentum may become withdrawn 
from a single loop, and fatal haemorrhage result. 

Never forget that all abscesses of the abdomi- 
nal wall should be opened freely and at once. 

Never hesitate or delay to open and drain an 
abscess in the loin, due to rupture or injury to the 
kidney. 

Never aspirate for ascites, or for any fluid col- 
lection in the peritoneal cavity, without first empty- 
ing the bladder. 

Never aspirate a large ascitic collection quickly. 
Do it slowly, so as to avoid shock. This rule holds 



86 GOLDEN RULES OF SURGERY. 

good for thoracic and vesical as well as for intra- 
peritoneal collections. 

Never aspirate a suspected renal tumor 
through the peritoneum. Enter posteriorly below 
twelfth rib. 

The time patients are required to remain in bed 
or in the hospital after abdominal section, has 
been very much reduced. A few days only are 
now required after extensive operations, where 
formerly six weeks were insisted on. After appen- 
dicectomy or radical cure of hernia, patients may sit 
up after 4 or 5 days and may often leave the hos- 
pital after one week. This rule applies only to 
afebrile cases with primary union. 



IRRIGATION AND DRAINAGE. 



Irrigation and Drainage in Abdominal Surgery. 



Never irrigate over a wider area than has been 
contaminated. 

Never use pure water — it is irritating — always 
saline, 1 per cent. 

When the infection is limited to the pelvis, limit 
the irrigation strictly to this part. 

Never forget the renal fossae in drying out the 
abdomen; much fluid is liable to collect there. 

"Drainage is rarely of value and often harm- 
ful," says Howard Kelly, vol. II, p. 29. But I do 
not agree with this bald statement. Drainage is 
often of great value and is rarely harmful. I have 
saved many lives by drainage after appendix and 
pus-tube operations. This is not the place to har- 
monize the two contradictory sentences. Both are 
right, both are wrong, but in quite different cir- 
cumstances. If both methods seem applicable then 



88 GOLDEN RULES OE SURGERY. 

the operating surgeon must decide which method 
he will follow and let no man censure him for his 
choice— for he will know best which method is 
suited to his plans as he has learned to use them 
in previous experiences. 

While on the subject of drainage remember the 
great part which the lymphatics play in disposing 
of poisonous and waste matter. 



abscess. 89 



ABSCESS. 



Never try fluctuation across a limb, always 
along it, but remember that there may be fluctua- 
tion, even though you can not detect it. Let some 
other surgeon try his sense of feeling. 

Never forget that : — 

1. — Abscesses near a large joint often com- 
municate with the joint. 

2. — Abscesses near a large artery sometimes 
communicate with the artery. 

3. — Abdominal wall abscesses sometimes 
originate in affections of the hollow or solid 
viscera. 

If the abscess is widely opened, drainage with 
gauze will suffice without irrigation. Dispense 
with irrigation whenever you can get along with- 
out it. 



90 GOLDEN RULES OE SURGERY. 

Never forget that early openings are imperative 
in abscesses situated: 

1. — In the neighborhood of joints. 

2. — In the abdominal wall. 

3. — In the neck, under the deep fascia. 

4.- — In the palm of the hand. 

5. — Beneath the periosteum. 

6. — About the rectum, prostate and urethra. 

After incising the skin introduce the aseptic 
finger and be sure that any side-pocket is also 
drained. 

To wait for abscesses to "point" or to "burst" 
in these situations is culpable as well as cowardly. 
There is no danger of infecting an abscess by its 
own contents. The walls surrounding the abscess 
are probably immune to the germ poison they con- 
tain. Of course you can introduce foreign germ 
poisons if fingers and tools are not clean. 

Remember the frequency with which haema- 
tomata and traumatic aneurysms have been mista- 
ken for abscesses, and have been incised with un- 
toward results. 



ABSCESS. 91 

Do not open a collection of pus anywhere near 
a large artery without first using a stethoscope. 
It is best to incise an abscess thus situated by Hil- 
ton's method (i. e., scalpel, director, and dressing 
forceps). 

Never under any circumstances use for explora- 
tory puncture "that surgical abomination — a 
grooved needle" — for it causes contamination of all 
the tissues through which it is withdrawn, if it has 
entered an abscess. (Thornton.) 

Never plunge in opening abscesses; never 
squeeze the sac after opening. 

Always use the moist antiseptic pack after 
opening an abscess. 

The moist antiseptic dressing has taken the 
place of the old poultice. It is better in every way. 
(See "Moist Dressing.") 

Do not forget that your incision should radi- 
ate : 

1. — In abscesses pointing near the nipple. 

2. — In abscesses near the anus. 

3. — In scarifying chemosis of the conjunctiva. 



92 GOLDEN RULES OF SURGERY. 

And that your incisions should be longitudinal : 
1. — In the hand. 
2. — In the perineum. 
3. — On the vertex. 

Do not forget that incisions for superficial ab- 
scesses in the neck and face should run parallel 
with the wrinkles and folds. 

Do not be afraid of hurting the lacteal tubes in 
mammary abscess. More harm is done to the 
gland by the burrowing of pent-up pus, than by a 
free incision. 

Never make a palmar incision for abscess ex- 
cept in the middle of the lower third and in the 
axial line of the fingers or at the sides of the palm. 

Do not forget, in opening a deep abscess in the 
lumbar region, outside the bulging area, to cut 
down opposite a transverse process for fear of 
wounding a lumbar artery. 

Never go deeper than for four inches into the 
liver when aspirating, by this means you avoid the 
inferior vena cava. 

Remember the sinus or fistula is the relic of 
a former abscess and that if it does not heal and 



ABSCESS. 93 

close permanently under the influence of rest, ar- 
tistically and scientifically applied for a sufficient 
time, a radical cause must be sought and removed. 

Never neglect the hint which the guardian pap- 
illae give of the irritating focus deeper down. 

Remember a dirty probe will cause fever ; even 
a clean probe energetically used may cause fever 
by baring the granulations lining the sinus. 

The mere curettement of a sinus, if it does 
not lead to the discovery and removal of its cause 
is useless. 

Never neglect to slit up the forks and the bur- 
rows of the sinus or fistula as well as the main 
channel. This applies not only to perirectal but to 
all fistulas wherever located. 

In order surely to find all forks and branches 

of a sinus the injection of a staining fluid will aid 
the surgeon so that none will be overlooked. 
Methylene blue or pyoktanin solution is good for 
this purpose and may be injected with considerable 
force. (C. H. Mayo.) 



94 GOLDEN RULES OE SURGERY. 



ANEURYSM. 



Never attempt to cure an aneurysm by the for- 
mation of a thrombus if the patient has any septic 
condition (such as an abscess, sore, suppurating 
otitis), for such may induce yellow softening of 
the clot. 

Extirpation of the sac is the best method of 
cure. The old Antyllus method of ligating above 
and below the sac and removing the latter is the 
best as well as the most radical method where the 
anatomical relations will permit its performance. 
It should be used to the exclusion of those meth- 
ods which merely ligate the artery and leave the 
sac. This operation is now often successfully done 
because it has lost its former dreadful mortality 
since we operate aseptically. 

Aneurysm of the aorta is a noli me tangere. 
Asepsis has left some lesions in the class of inop- 
erable cases. 



APPENDICITIS. 95 



APPENDICITIS. 



When a surgeon sees a case of appendicitis 
within 12 hours of its inception and can operate 
before twenty-four hours have passed, he may re- 
joice, because he has an excellent chance to save 
an endangered life. He will succeed ninety-nine 
times out of a hundred. 

If a surgeon is called after twenty-four hours 
have elapsed and can not operate under favorable 
conditions before another twelve hours or longer 
have elapsed, he must not always operate. The 
death rate is high when operations are done during 
the acute attack after the first thirty-six or forty- 
eight hours have elapsed. 

The time will come when physicians who allow 
the most favorable time to pass by and call for a 
surgeon too late, will receive censure. I am, as a 



90 GOLDEN RULES OF SURGERY. 

matter of fact, of the opinion that the time for such 
censure has now arrived. (1906.) 

I am as a matter of principle in favor of the 
prompt operation in all cases when seen early 
enough. 

In those cases where, because of failure to make 
a prompt diagnosis, or for some other reason, the 
first thirty-six hours have passed, the expectant- 
purgative treatment should at once be instituted 
if the operation is regarded as too dangerous. 

This expectant treatment will lead to a cure, or 
rather to an apparent cure in about 80 per cent, 
of the cases. Of the other 20 per cent, perhaps 5 
per cent, will require operations of drainage in or- 
der to save their lives and will be very ill for 
weeks and months, the remaining fifteen per cent, 
will die. 

The prompt radical operation done during the 
first twenty-four, or at the longest, thirty-six hours, 
has a mortality of one per cent; the expectant 
treatment a mortality of fifteen per cent, and in 



APPENDICITIS. y ( 

many cases a long siege of fever and confinement 
in bed. 

An interval operation for the removal of the 
impaired and adherent appendix will be necessary 
in a large number of those who have escaped with 
their life under the expectant treatment. Exactly 
how many of this 85 per cent, will submit to the 
interval operation we never can know, but their 
number is constantly growing. 

I consider the interval operation a safe one and 
believe it should be done in nearly all cases. Its 
mortality is below one-half per cent. This means 
that less than one out of two hundred cases will 
die after the interval operation in the hands of an 
aseptic and skillful operator. 

At the meeting of the German Society for Sur- 
gery in 1905, the consensus of opinion of those 
who have had the largest experience was in favor 
of the early operation as a routine practice, before 
36 hours have elapsed. 'We American surgeons 
have entertained this opinion for some years past, 
but have met with opposition from the general 
practitioners. 



98 GOLDEN RULES OE SURGERY. 

Let the general practitioner remember that the 
mortality of appendicitis operations done on the 
3d, 4th or 5th day is from 15 to 20 per cent, and 
let him also know that the mortality in cases done 
before thirty-six hours have elapsed is only one per 
cent, in the hands of the same surgeons, and he 
will soon realize that the safety of his patients 
lies in prompt diagnosis and operation. 

I once had the great luck to operate on seventy 
cases of acute appendicitis in succession without a 
death. I call it great luck in the light of subsequent 
experience, because I have never had so low a 
mortality again, although my experience and my 
technique have grown since then. Some of these 
cases were late cases done on the 4th, 5th or at a 
much later time. The majority of course were 
early cases, but some had diffuse peritonitis. This 
was in 1894 and '95 when I operated on all acute 
cases as a matter of principle, no matter when 
called to see them. 

I desire here again to emphasize my view based 
on a large series of cases, that the expectant pur- 
gative method of treatment will get better re- 
sults in the hands of the general practitioner than 



APPENDICITIS. 99 

the opium-starvation-treatment of long ago, which 
by some has been called the Ochsner treatment. 

In these unoperated cases of appendicitis we 
are dealing with cases that were formerly called 
cases of peritonitis or perityphlitis. In these cases 
we are combating septic absorption of putrid ma- 
terial located both inside and outside of the intes- 
tinal tract. I consider that the best method is to 
enhance elimination by purgation. In my opinion 
the physician will do well to give an enema of warm 
water and some small doses of calomel, as soon" as 
he recognizes appendicitis. The operator who may 
perform the operation a few hours later, will find 
his work much easier if the bowels have been 
cleaned out, than if they are expanded by gas and 
faeces. Even if an operation is not done the ex- 
pectant treatment will have the benefit of this evac- 
uation of the bowels, which is always accompanied 
by more or less of an elimination of waste material 
which has accumulated in the intestinal sewers. 

Remember that at the present time we have no 
way of knowing before the operation whether it is 
the bacillus coli, or the streptococcus or some other 
kind of infectious micro-organism which is con- 

LOFC. 



100 GOLDEN RULES OF SURGERY. 

cerned in any given case of appendicitis. This is 
one of the plainest reasons why we can never offer 
a prognosis in a case of appendicitis and should al- 
ways recommend prompt removal of the organ. 

The reason why appendicitis is so frequent, is 
because the appendix is a rudimentary organ. A 
rudimentary organ is one that has lost its useful- 
ness. It is one that is on the list of organs which is 
being abolished by the slow process of evolution. 
Organs of this kind are not well equipped with 
vitality or with resisting power. Their blood ves- 
sels, lymphatics and nerve supply are also grad- 
ually being evolved out of existence. Hence this 
organ is so frequently found undergoing processes 
of degeneration and of necrosis, which lead to fatal 
peritonitis in very many cases, unless prompt re- 
moval of the organ is effected. 

That the appendix vermiformis in man is a ru- 
dimentary organ is proven by the fact that it is 
proportionately much larger and wider and longer 
in a foetus of three months than at birth of the 
child or at any time later. 

Remember that while performing appendicec- 



APPENDICITIS. 101 

tomy, there is danger of hernia following a 
large incision. Bnt do not make the incision so 
small as to hamper you in doing a perfect and com- 
plete operation. An interval operation rarely re- 
quires a long incision and during the acute stage 
the incision will probably always be longer in late 
cases than in the very early ones. Another reason 
for the prompt early operation. 

That the autoptical method of pathological 
study or research has great advantages over the 
autopsical or nekropsical method is easily under- 
stood. Aseptic surgery has given us material in 
plenty for macro- and microscopical examination 
taken from the living and curable patient intra 
vitam. The post-mortem, or autopsical, method of 
pathological research acquaints us only with the 
terminal or incurable stages of disease. 

Our modern knowledge of appendicitis has been 
much advanced by autoptical observation in vivo 
and would still be in "darkness if we depended on 
the old post-mortem pathology. 



102 GOLDEN RULES OF SURGERY. 



ARTERY-BLEEDING. 



Always tie both ends of a divided artery in a 
wound. 

The best ligature is catgut. Bartxett's method 
of preparing it seems to make the most useful 
threads. It is strong and also elastic. 

Unless there is a valid reason against it always 
use catgut for suture or ligatures. 

Remember that not every little artery needs 
tying; a clamp left on for a few minutes often suf- 
fices and avoids a foreign substance in a wound. 

Use as thin a ligature as seems consistent with 
the required strength. Avoid thick sutures and 
ligatures. 

Twisting arteries is just as safe as tying — when 
well done it is the preferable method, but it is not 
so easy as tying and should not be used by inex- 
perienced surgeons. Learn how to do it. 



ARTERY BLEEDING. 103 

Remember that arterial haemorrhage must be 
checked at once and permanently and that there 
can be no exception to this rule, because death in- 
evitably follows the loss of blood, if it persists. 

. On the other hand it is important to know that 
the organism can stand the loss of large quantities 
of blood. I have seen strong men or women re- 
cover who had lost 6 or 8 pounds of blood. A man 
weighing 150 pounds has about 12 pounds of blood 
in circulation, and the loss of one half of it will 
not kill unless it spurts out of a large artery in a 
few minutes. In this event, by proper treatment 
of the shock recovery often takes place. 

Proper treatment will be infusion of warm salt 
solution by subcutaneous, intraperitoneal or rectal 
injection. Direct intravenous transfusion of fluids 
of any kind is not to be commended. It seems 
safer to have the fluid enter the blood vessels 
after having passed through a cell membrane of 
some kind. 

The use of strychnine, digitalis or other poisons 
by hypodermic injections is not recommended, be- 
cause they do more harm than good and often kill 
weak patients. 



104 GOLDEN RULES OE SURGERY. 



BONES AND JOINTS. 



Always hesitate to diagnose in an off-hand way 
"rheumatic" pain in young children, and those 
about the age of puberty. Remember acute peri- 
ostitis simulates rheumatism very closely. 

Remember that the diagnosis of "growing 
pains" in children is slipshod and usually incorrect ; 
that it has been known to cover myalgia from fa- 
tigue, rheumatism, diseases of the joints and bones 
of the lower extremities, even fevers. 

Never delay in acute osteo-myelitis or in acute 
infectious periostitis to cut freely down to a bone 
as soon as the nature of the case is detected. Every 
hour of delay may need a month to repair. 

Do not forget the three golden rules in acute 
osteo-myelitis of the fulminating type : 
1 . — Prompt , incision. 
2. — Free incision. 
3. — Free drainage. 



bones. 105 

Remember secondary abscesses may form in 
acute osteo-myelitis. Be therefore on the qui vive 
for such. 

Do not be disappointed if, on making incisions 
down to the bone, you evacuate but little pus in 
acute osteo-myelitis. It makes no difference, the 
relief afforded is often the same. 

Remember the golden rules for removing se- 
questra from long bones after necrosis. 

1. — Do not wait for the periosteal sheath 

(new bony sheath) to acquire strength 

enough to preserve the continuity of the 

limb. 
2. — Always remove the sequestrum as soon 

as possible, for it is : 

i. — A permanent source of irritation. 

ii. — A danger to the adjacent parts. 
3. — Do not leave any dead bone behind. 
4. — Always splint carefully and bandage to 

maintain the parts in apposition and to 

prevent fracture. 

Never forget that there is no periosteal sheath 
in the necrosis of the femur in the popliteal space, 



106 GOLDEN RULES OF SURGERY. 

and that the exfoliated bone lies close under the 
popliteal artery. 

In removing such a sequestrum avoid four 
things : 

1.— Joint. 

2.— Artery. 

3. — External popliteal nerve. 

4. — Rough manipulation. 

Do not use the knife. Separate with the han- 
dle of the knife or other blunt instrument. 

At the present time the rule is : Amputate 
where the limb-maker can best supply the loss. 
The old points of selection are not always the best. 



JOINTS. 



107 



Joints. 



Remember that chronic joint disease in most 
cases originates in the bone and is tuberculous. 
Even when a trauma is given as the cause, it is 
usually not the primary cause, the latter is likely 
to be a tuberculous focus in an epiphysis near the 
joint. 

Never bandage an elbow in the extended posi- 
tion excepting after fracture and wire suture of 
the olecranon. 

Do not be hasty with the knife in dealing with 
fluctuating swellings near a joint. [There are 
changes in the synovial membrane which produce 
thickening and suppuration, which can with diffi- 
culty be distinguished from an external circum- 
scribed abscess.]. 

Never forget that the synovial tissue of thecae 



108 GOLDEN RULES OE SURGERY. 

embracing tendons, may pour out a considerable 
amount of fluid or even pus. - [The accumulation of 
fluid in a joint or in the layers of the synovial mem- 
brane or in tendons and bursae rarely affects the 
integument. Therefore, unless there is external 
redness never use the scalpel hastily.] 

Never probe any joint in clean cut wounds open- 
ing the joint, unless a foreign body is known to 
be lodged therein. 

Always persevere with rest and counter-irrita- 
tion in disease of the shoulder-joint as long as there 
is pain produced by motion, but no longer. . [Pro- 
longed confinement is apt to produce adhesion of 
the lower part of the capsule, and permanently to 
deprive the patient of the power to raise the arm]. 

Always trace all sinuses near the shoulder to 
their source, because the tendons often direct the 
pus to some point distant from the joint. 

Always consider the chance of subacromial bur- 
sal disease before you diagnose disease of the 
shoulder-joint. 



JOINTS. 109 

Do not hesitate to aspirate a joint for diagno- 
sis, but remember it is criminal to do so without 
strict aseptic precautions. 

Never neglect to put all tuberculous joints at 
rest. [Rest should be maintained for three months 
after all signs of disease have vanished, and active 
exercise must even then be very gradually re- 
newed]. 

Never neglect early movement in chronic ar- 
thritis ; never allow early movement in tuberculous 
arthritis. 

Never insist on maintaining fixation of joints 
for over long during the treatment of accident or 
disease of the limb itself. 

Never forget whilst breaking down adhesions 
in a joint: 

1. — The atrophy of bone which rest induces. 

2. — The buried bacillus. 

3. — The fragility of a child's bone. 

Hence in breaking down adhesions do not omit 
to hold the bones as near the joint as possible. 



110 GOIvDEN RULES OF SURGERY. 

Do not do too much at once. Rupture adhesions 
by short movements in the way of flexion. Divide 
contracted tendons some days before breaking 
down adhesions, and put on the ice-bag in every 
case afterwards. 

Beware of employing brisement force in tu- 
berculous joints. [Numerous cases are recorded 
where this procedure was followed within a few 
days by general miliary tuberculosis and a speedy 
death]. 

Never attempt to overcome muscular contrac- 
tion by forcible extension in remedying malposi- 
tion of joints — tenotomize. 

Do not let a child wearing a Thomas' splint 
have a hard bed, for the splint on a hard mattress 
is thrown out into relief, and causes painful pres- 
sure. 

Never forget that the rapid loss of tissue ob- 
served about a joint in serious disease of the ar- 
ticulation is never seen in hysterical joint. 

Remember that in making a resection of dis- 
eased, tuberculous joint ends of bone the soft parts 



JOINTS. Ill 

surrounding the excised area, though perforated 
by numerous old fistulae or sinuses, need not be 
removed. They will all heal up if their cause has 
been removed by the operation. 

Beware of the insidious onset of tuberculous 

arthritis. 

Never regard the case of a limping child light- 
ly. Examine the hip. 

Never omit to examine the hip when pain is 
complained of in an apparently healthy knee. 

Never forget that proof of knee disease is no 
proof of the absence of hip disease of the same 
side. 

If it is possible to give a diseased joint perfect 
rest, by means of bandages, splints or casts, and to 
supplement this treatment by outdoor life in a suit- 
able climate, the results of the treatment of dis- 
eased joints are most satisfactory. 

If ever you must exarticulate at the hip joint, 

ligate the common iliac artery transperitoneally 
first. This little operation will take a few minutes 
and will render the amputation much easier and 



112 GOU>EN RULES OF SURGERY. 

less bloody than either Sinn's or Wye}Th's long 
pin method. I have done this in the last four 
cases of this kind, saving all of them. 



BREAST. 113 



BREAST. 



Never forget that a "tumor" in a young wom- 
an's breast is frequently a chronic abscess, or a 
cyst. 

Never procrastinate wth a tumor of the breast 

in a female over forty. 

Never excise a mammary tumor of doubtful 
nature without first cutting it across to examine its 
character. 

Never remove a true carcinoma of the breast 
without clearing out the axillary glands. Do not 
hesitate to remove the major and minor pectoral 
muscles, if you find hardened lymph glands under 
them. 

Never be too anxious to make your flaps meet 
and look well, in removing a cancer of the breast. 
Your vanity might tempt you to leave a flap in 
which cancer may lie concealed. 



114 GOLDEN RULES OF SURGERY. 

Although the temptation to do so is great, don't 
try to cover the wound with skin likely to contain 
cancer nodules. If you make a plastic operation 
by transposing a skin flap let the skin flap be taken 
from a distal location, distal referring to the 
course of the lymphatics. 

When extirpating a malignant tumor in the 
hope of achieving radical cure always remove the 
proximal lymphatics for a space of from three to six 
inches or more. This applies to all localities not 
only to the axilla. 

Remember that not only must a flap have arte- 
rial blood supply, but that the outlet or exit by the 
veins must be freely maintained. It is as important 
for the life of the flap as the arterial supply. 



BURNS. 115 



BURNS. 



Never give morphine hypodermically in burns 
of children; you cannot recall it. Give it by the 
mouth if indicated at all. Relieve pain by moist 
dressings of the proper warmth and alkalinity. 
Gauze saturated with sterile carron oil is a good 
dressing. 

Never omit an anaesthetic in the first dressing 
of extensive burns. Excellent results can be ob- 
tained by the simple aseptic or antiseptic moist 
dressing. (See moist dressing.) 

Beware of strong application of carbolic oil in 
burns, and, if it be used at all, watch the urine for 
absorption signs (a greenish brown coloration). 

Do not dress too often, but never let the dress- 
ings foul. 

Never uncover the entire wound at once ; do it 
piecemeal. 



116 GOLDEN RULES OE SURGERY. 

Always have the tracheotomy instruments at 
hand in burns and scalds of the mouth, because of 
oedema of the glottis. 

Remember the deformities which ensue on con- 
traction of cicatrices of burns, and attempt to pre- 
vent them by grafting, etc. 



CHEST. 117 



CHEST. 



Do not be very solicitous in obtaining crepitus 
of a fractured rib. Treat it as such. 

Do not handle portions of two different ribs in 
manipulating either side of the fractured rib to ob- 
tain evidence of undue mobility. 

Never forget that all penetrating wounds of the 
chest, involving fracture of ribs or not, should be 
closed at once and a plaster of Paris jacket put on 
at once. This is the most successful method of 
treating penetrating gunshot wounds of the chest. 

Do not forget that it is good practice in severe 
cases of fractured ribs, and in those in which the 
lung is wounded, to support the chest by com- 
pletely encircling it with plaster of Paris bandages. 
These are applied over the wound dressing. [Ban- 
daging is said to be contraindicated if there is much 



118 GOLDEN RULES OF SURGERY. 

comminution or tearing of the parietes of the chest ; 
or: 

1. — If dyspnoea increases on its application. 

2. — If pain is caused by^it; but I have found 
that breathing becomes easier and regular 
after a strong supporting bandage encir- 
cles the chest. Diaphragmatic breathing 
must take the place of costal breathing 
and nearly always suffices. 

Do not strap or bandage, if there is much sur- 
gical emphysema. Strapping is worse than useless 
if it only partly encircles the chest; to do good it 
must go clear around. 

Always regard rib injuries in old people with 
anxiety. [There may be, and usually is, pre-exist- 
ing emphysema and bronchitis which will hamper 
the breathing greatly.] 

Be cautious in fractures of- the ribs about ex- 
hibiting opium if the sputum is very viscid or very 
abundant. In the former case its tenaciousness is 
increased by the drug; and in the latter the nerv- 
ous reflex is dulled, and the stimulus for the con- 



CHEST. 119 

stant removal by coughing is lessened. Whiskey 
is preferable to opium if either is called for. 

Never tap. a chest in paracentesis without mak- 
ing certain by auscultation and percussion that you 
are on the right spot. 

Always use an exhaustion syringe in tapping 
the chest. Never forget in this, as in all other as- 
pirations, to run some carbolic or hydrarg. perch- 
lor. solution through your cannula and exhaustion 
bottle before operating. 

Do not forget your land-marks (upper border 
of lower ribs). 

Do not forget also that too forcible a suction 
applied to the vascular false membranes, which 
often occupy the pleural cavity, may give rise to 
haemorrhage into the pleura. 

Always stop the aspiration if pain is complained 
of. 

Do not neglect, in treating empyema, to secure 
your drain tube from slipping into the thorax. Let 
it be sufficiently, and only sufficiently long to enter 
the cavity. Longer is needless. 



120 GOLDEN RULES 0E SURGERY. 

Never forget that irrigation in empyema is 
rarely necessary, and is often fraught with serious 
danger. Leave the wound wide open for drainage. 
If perfect drainage is secured irrigation will not be 
needed. Moist dressing. 

Syncope, convulsions, and even death, due to 

reflex action, have been recorded. 

If it is necessary to irrigate, as it is exception- 
ally, never use a large amount of fluid; never 
throw it into the cavity roughly; never when the 
patient is sitting up; and never continue if pain is 
complained of. 



EAR. 121 



EAR.* 



Never forget that rupture of the membrana 
tympani, or even fatal consequences, may ensue 
from roughness in removing foreign bodies. 

Remember that no foreign body in the ear, ex- 
cept living insects or vegetable substances, can 
do harm. Syringe gently, unless the foreign body 
is likely to swell. 

Never forget that vegetable substances swell in 
the auditory canal on the application of water. 

Never forget the possible dangers of a dis- 
charge from the middle ear. 

Remember that there may be no discharge from 
the ear in lateral sinus pyaemia. 

Do not be thrown off your guard and decide 
against lateral sinus pyaemia because the dis- 



•Taken from Hurry Fenwick. 



122 GOU>EN RULES OF SURGERY. 

charge from the ear is inodorous and small in 
quantity. 

Always examine most carefully the nose and 
naso-pharynx in all cases of deafness for which no 
adequate cause has been found in the ear itself. 

Remember there is hardly any ear disease 
which may not be improved by removing any ab- 
normal conditions in the nose or naso-pharynx of 
a patient. A nasal polypus may cause deafness" as 
well as a mass of adenoid growth. 

Remember, a running ear may be often cured 
by clearing the post-nasal space. 



ERYSIPELAS. 123 



ERYSIPELAS. 



Never deplete or depress in erysipelas. Sup- 
port and stimulate. 

Do not dress operation or fresh wounds, or at- 
tend midwifery, if you are dressing a case of ery- 
sipelas or any contagious or infectious disease. 

It is in erysipelas that the moist pack, partic- 
ularly the moist bichloride of mercury pack, has its 
most striking and gratifying results. 

In mixed infections and lymphangitis of all 
kinds you will be able to achieve therapeutic 
triumphs by this method. (See Moist Dressing.) 



124 GOU>EN RULES OF SURGERY. 



FEVER. 



Remember the real danger in fever is not the 
pyrexia, but the poison causing it. Fever is, in a 
measure, a beneficial process operating to protect 
the economy. The elimination of the poison by 
the skin, kidneys, liver, and intestines is the thing 
to be encouraged. 

Always view with anxiety any case of sepsi.s 
which has a low temperature and a rapid pulse. 
The prognosis is more favorable when the animal 
economy responds with a positive but controllable 
pyrexial process, than when there is very little feb- 
rile reaction. 

I have seen no harm from the use of properly 
prepared antitoxic serums, but have not seen the 
excellent results claimed for them. They are still 
sub judice. The whole theory reminds me of the 
old humoral pathology and is not scientifically es- 
tablished. Festina lent el 



FEVER. 125 

To drive down the temperature by means of 
antipyretic coal-tar products is sometimes harmful. 
Symptom treatment before the diagnosis is always 
fighting an unknown enemy in the dark, conse- 
quently always uncertain and unsafe. 



126 GOU>EN RULES OE SURGERY. 



FRACTURES AND DISLOCATIONS. 



The principles underlying the treatment of frac- 
tures may be stated as follows: 1st, correction of 
deformity by reposition or reduction of the frag- 
ments; 2nd, retention or fixation of the broken 
bone after the displacements have been put into 
apposition, by suitable retention dressing or appa- 
ratus until bony union has taken place. 

In compound fractures the wounds will be 
treated antiseptically and unless the compound 
fracture can be made into simple fracture by su- 
ture of the wounds, means of drainage and anti- 
septic wound treatment will have to be provided 
for in conjunction with the cast or apparatus of 
fixation. 

Should attempt at making a simple out of a 
compound fracture fail, as will be shown by the 
thermometer on the second or third day, all dress- 



FRACTURES AND DISLOCATIONS. 127 

ings must be removed and the free drainage pro- 
vided for at any cost of trouble and time, amputa- 
tion may be indicated. 

The use of the plaster of Paris dressing of frac- 
tures, must be acquired by all surgeons and is not 
at all easy or simple. It can be learned only by 
experience. The thing to be learned is how to 
achieve fixation and rest without undue pressure. 
Flannel bandages under the plaster are preferable 
to cotton batting. 

Next in importance to learning the use of plas- 
ter of Paris is to learn that anaesthesia will facili- 
tate the perfect reduction or setting of fractures 
and dislocations and that complete relaxation of 
the muscles by chloroform or ether insures an exact 
diagnosis and also a more accurate reposition and 
restoration of the broken or displaced structures. 

Remember that crepitus may not be obtained 
in : 

1. — Riding of fragments. 

2. — Impaction of fragments. 
3. — Entire separation of fragments. 
4. — When muscle or blood clot is interposed 
between fragments. 



128 



GOU>EN RULES OF SURGERY. 



Remember that there is a pseudo-crepitus, very 
like true crepitus, in teno-synovitis, joint effusion, 
osteo-arthritis, and caries of a joint surface. 

Do not forget that in epiphyseal fracture your 
prognosis must be guarded, because such injuries 
to the young are sometimes followed by suspended 
growth or by premature ossification of the bone. 
Deformity is thus produced. 

Remember, in separation of epiphysis in the up- 
per extremity of the humerus and the lower ex- 
tremity of the femur, the line of fracture is so 
broad that there will be no shortening, but the 
fragments will project. 

Always examine at once the pulse at the wrist 
and ankle in fractures of the humerus and femur, 
to ascertain if the artery has been torn. 

Never allow a splint to press on the skin, so as 
to ca.use ulceration or oedema, or worse, gangrene. 

Do not in fracture of the acromion put a pad 
in the axilla, or bandage the elbow too tightly to 
the chest, because the head (the natural splint in 
such fractures), is thrown outwards and the frag- 
ments are separated. 



fractures and dislocations. 129 

Never forget to examine the shoulder joint in 
every case of fracture of humerus situated high 
up, in order to ascertain whether the head be dis- 
located or not. 

Never omit in fracture involving the elbow- 
joint to commence passive motion on the seventh 
day — certainly not later than the fourteenth day. 

Do not splint the palm of the hand in Colles' 
fracture ; leave the fingers free, and work them 
after the third day, for the tendons as they cross 
the back of the radius — the seat of fracture — are 
apt to become adherent to their grooves. 

Never let your diagnosis be "only a contused 
hip" in old people, without a very careful and gen- 
tle examination to exclude impacted fracture. 

Do not forget that though absorption and 
change in the head and neck of the old femur is 
not so common as is taught, yet it does take 
place as the result of chronic osteo-arthritis, and 
may simulate fracture in the shortening, eversion, 
and osteophytic crepitus, which are so often pres- 
ent. 



130 GOLDEN RULES OF SURGERY. 

Never use violence in order to elicit crepitus in 
cases of hip injury; much damage may be done in 
separating an impaction by rough examination. 

Do not keep your old patients in bed, in order 
to get union in hip fracture. They are almost sure 
to suffer from sloughing produced by the splints 
or from bed sores, and will very likely die. 

Never forget to bandage the entire limb in frac- 
tured femur. The best treatment is the plaster of 
Paris cast, bandage encasing the foot, leg, thigh 
and pelvis by spica, reinforced throughout with 
strips of tin, the whole applied standing, supported 
on the sound -leg. See remarks about plaster of 
Paris. 

Remember the danger of traction by an exten- 
sion weight if a fracture be transverse above the 
condyle of the femur [the popliteal artery is 
brought into contact with the sharp edge of the 
lower fragment]. 

Always shampoo the quadriceps in a fractured 
patella, provided the state of the soft parts per- 
mits it. 



fractures and dislocations. 131 

Never place recent fractures in plaster of Paris 
splints (or other splints which withdraw the seat 
of fracture from the surgeon's observation), if 
there be much bruising, or until such has subsided. 

Always use fixation in recent fractures but ex- 
plain the danger of subsequent swelling to - the 
patient and obtain his consent when the fracture 
is seen early enough. 

The two apparent contradictions just noted be- 
ing understood, the plaster of Paris cast is the best 
treatment for recent fracture. If it can be applied by 
one thoroughly familiar with its use and technique 
soon after the accident has occurred there will be 
but little swelling and no pain. Should there be 
pain after the plaster has set then probably the ap- 
proximation is faulty and must be changed at once. 
Should pain occur a few hours later and persist, 
then swelling has occurred and the cast must be 
removed and a new one put on as soon as possible. 
The neglect of this rule may, and nearly always 
does, bring on ischaemic paralysis with its ruinous 
sequences.* 



*See paper on Ischcemic Atrophy, etc., after tight bandaging, in Boston 
Med. and Surg. Journal, June, 1900, by the author. 



132 GOLDEN RULES OF SURGERY. 

Always suspect a bone that is fractured on 
silght violence. It is suggestive of disease, e. g., 
central sarcoma. I have seen a man break his 
femur pulling on a boot under these circumstances. 



DISLOCATIONS. 133 



Dislocations. 



Never attempt to reduce a dislocation of the 
humerus in an old person without first examining 
the state of the brachial arteries to inspire you with 
caution and gentleness. You can produce trau- 
matic aneurysm if the arteries are atheromatous 
and brittle. [A case by Lord Lister, Lancet, Jan. 
4, 1890]. 

Never put a booted foot in the axilla to reduce 
dislocation. 

Always reduce by some other method than the 
foot in the axilla if ribs are broken on the same 
side. 

Always clear up two points in treating injuries 
of the upper end of humerus. — Is there dislocation 
of the head? or, Is there fracture of the neck of the 
scapula? 



134 



GOLDEN RULES OF SURGERY. 



Never give a positive opinion of an elbow joint 
until you have carefully examined the relations of 
the olecranon, internal and external condyles, and 
head of radius. 

Never be ashamed to say you "do not know" 

until the swelling has subsided, and you are able to 
be certain of the character of the injury. 

Always anaesthetize the patient if the disloca- 
tion is an old one and if there have been fruitless 
efforts at reduction made by others previously. 
The anaesthesia must be complete, and must pro- 
duce perfect relaxation of the muscles. 

Remember, however, that in dislocation at the 
elbow, the joint becomes rapidly irreducible, and 
that a faulty diagnosis may cause loss of motion in 
the joint. 

Always have obscure injuries to joints radio- 
graphed at once, if ways and means permit. Es- 
pecially do this in shoulder and elbow joint cases. 

Do not forget in dislocation of the carpal bones 
that the great point is to see that the motions of 
the fingers are restored early. 



DISLOCATIONS. 135 

After a luxation has been reduced the swelling 
rapidly subsides, and the joint may be used after 
a short time of rest. Should the swelling and pain 
persist then either the reduction was imperfect or 
the bone has again slipped out of place. 

Should this accident happen the patient must 
again be anaesthetized and a plaster of Paris band- 
age applied before the patient awakens. 



136 GOLDEN RULES OF SURGERY. 



GALLSTONE DISEASE. 



As long as stones are in the gallbladder the di- 
agnosis is not easy, because it rests largely upon 
subjective testimony of the patient and the trouble 
is often referred to the stomach. 

The operation of these cases is easy and the 
prognosis favorable, whether natural cholecysto- 
tomy or ideal cholecystotomy is done. 

Cholecystectomy should not be done as a rule 
unless the gallbladder is diseased. 

Obstruction of the common duct by a stone is 
easily diagnosed by means of the jaundice and 
other characteristic symptoms. In these cases the 
operation is difficult and dangerous. W. J. Mayo 
has done much to clear up this condition and I 
must refer to his writings for operative details. 
Drainage of the duct after removal of the stone 
seems the safest method of treatment. 



GALLSTONE DISEASE. 137 

In this condition again early operation before 
serious complications arise is the proper thing. 
When the diagnosis is uncertain an explorative 
incision will be indicated in some cases. 

When the belly is open it is as well to look after 
the gallbladder as other organs. 

Gallstones are not so harmless as was formerly 
thought. 



138 GOLDEN RUIJ5S OF SURGERY. 



GANGRENE. 



Do not mistake the line of discoloration in gan- 
grene for the line of demarcation. The former 
spreads, the latter rarely moves. 

In senile gangrene do not neglect the only drug 
of use — Opium ; give it while you a,re awaiting the 
time to do an amputation high up. 

Do not hurry separation of sloughs in frost-bite 
gangrene. Always treat moist gangrene with the 
antiseptic moist dressing. Give rest by suitable 
splint and change the dressing once a day. 



GENITO-URINARY. 139 



GENITOURINARY. * 
I. Bladder and Urethra. 



Remember that the "fades" of tubercle may 
not be noticeable in urinary tuberculosis, and that 
the "cachexia" of malignant disease only appears 
in the last stage of cancer of the bladder. 

Remember that the introduction of an instru- 
ment is more or less of an evil, never to be resorted 
to, unless a greater evil be present, which its em- 
ployment may probably remedy. (Sir H. Thomp- 
son.) 

Beware of diagnosing hysterical retention in 
the female. Many women have suffered a life-long 
penance for a two days' unrelieved retention after 
parturition, or shock. False modesty, suspicion 
of hysteria, and negligence, have a heavy roll-call 



*Bladder and Urethra, Genital-Penis, Gonorrhoea, Kidney and Syphilis 
are taken unchanged from Mr. Hurry Femvick's Utiles of Practice. 



140 GOIvDKN RULES OF SURGERY. 

of ruined bladders. Better feed twenty drones 
than starve one bee. Better pander once or twice 
to twenty supposed cases of hysterical retention, 
than destroy the bladder of one healthy-minded 
woman. 

Never neglect to pass your hand over your pa- 
tient's belly in typhoid or any severe fever, or an 
injury to, or fracture of the spine, or in compres- 
sion, coma, or delirium, etc., in order to ascertain 
if the bladder be distended; for in these cases the 
bladder may be atonic and injuriously distended 
without distress. 

Never be content with simply washing your 
rubber catheter before using it in cases of fractured 
spine. Let it always lie in carbolic water 5 per 
cent. 

Never use force in passing catheters or bou- 
gies ; certainly never in cocainised urethrae nor in 
cases of fractured spine, because of the insensitive- 
ness of the urethra. [Every dresser or junior assist- 
ant ought to be induced to pass a full-sized bougie 
upon himself once or twice. He would then appre- 



GENITO-URINARY. 141 

ciate the need for the utmost gentleness in urethral 
instrumentation.] 

Never pass an instrument if your patient is suf- 
fering from an acute inflammation of the testicle 
— unless you are relieving retention, or unless the 
orchitis occurs in a patient habitually using a cath- 
eter. 

Be especially gentle in passing instruments on 
a monorchid, for orchitis in his case is tantamount 
to sterility. There is, however, a greater danger : 
when one testis is congenitally absent, the corre- 
sponding kidney may be also absent. 

Never pass any instrument (bougie, catheter, 
sound, or cystoscope), until you have examined 
the prostate; for you may find evidence there jus- 
tifying you in avoiding instruments. 

Do not permit yourself to talk glibly of "im- 
passable" stricture. Such cases are very rare. Pa- 
tience and a little sweet oil will often carry an in- 
strument through. 

Never under any circumstances dilate a stric- 
ture with a catheter — use an aseptic smooth-sur- 
face bougie. 



142 GOLDEN RULES OE SURGERY. 

Never aspirate a bladder suprapubically with- 
out feeling it through the abdominal wall. Do not 
trust to percussion. 

Remember that success in the dilatation of 
stricture is now-a-days not so much a question of 
personal skill as of well-made, flexible instruments. 

Never pass a jointed or screwed instrument, 
such as an urethrotome-guide, into the bladder 
without testing the joint or screw. 

Never forget that some stones lie "latent," and 
do not evoke characteristic symptoms. [This is 
especially the case in prostatic atony]. 

Do not forget that a "large" calculus is often 
a sign of incapacity, or of carelessness on the part 
of the medical attendant. 

Never sound for stone during a "fit of the 
stone" (an attack of cystitis), or if there be any 
suspicion of cancer of the bladder, without great 
circumspection, for severe haemorrhage and ag- 
gravation of symptoms generally follow in such 
cases. 

Never sound a patient suffering from "symp- 



GENITO-URINARY. 143 

tomless" haematuria (intermittent attacks of 
bloody urine, without pain or bladder irritability, 
the urine being normal between the haemor- 
rhages.) 

Never be in a hurry to sound a young or mid- 
adult patient with vesical irritability well marked 
at night. Night irritability is the clinical indica- 
tion of tuberculosis of the bladder. 

Always boil your sound, and have your patient 
in bed when you sound. Let his bladder be full ; 
elevate his pelvis on a hard pillow. Never omit to 
sound behind the prostate. Do not get your pa- 
tient up for twelve hours after sounding. 

Never forget that dribbling of urine in adult 
life usually denotes the overflow of a distended 
bladder. 

Never introduce a patient to catheter life with- 
out first giving him a course of urotropin (gr. 
vi: ter.) for three days at least. Give, always, ex- 
plicit directions concerning the cleansing of the 
catheter. 

Never under-rate the danger of an over-dis- 
tended "flabby" bladder in a male over fifty. 



144 GOLDEN RULES OF SURGERY. 

Beware of catheterizing an old man who has 
incontinence of urine, morning sickness, and pro- 
nounced thirst, whose bladder is distended well 
above the pubes, whose urine is clear, very pale, 
of low specific gravity, and abundant in amount. 
Explain the gravity to the friends. 

Never empty any bladder, and certainly never 
a largely distended bladder, quickly or in the erect 
posture, unless the patient is accustomed to the 
use of the catheter. 

Remember it is a rule with no exceptions that 
a patient with hypertrophied prostate is never safe 
unless he can pass a catheter for himself, any more 
than is a patient with hernia who does not wear a 
truss. (Keyes.) 

Do not forget that irritability of the bladder is 
sometimes due to renal, ureteral or rectal irrita- 
tion. 

Never inject more than 4 oz. at a time into the 
bladder, and that only with care. 

Never remove a catheter a demeure roughly or 
rapidly. [The abrasion of the canal by the eroded 
instrument has caused suppression and death]. 



GKNIT0-UR1NARY. 145 

Never put on a cantharides blister in nephritis, 
because of absorption (use L,iq. ammon. fort.) 

Do not forget that a stricture whose calibre has 
been found by a genito-urinary specialist to be No. 
4 (French) often easily permits a 28 (French) to 
pass. — (Ohmann-Dumesnil) 



146 GOLDEN RUIvKS OF SURGERY. 



II. Genital-Penis. 



Never sanction a lengthy or an adherent pre- 
puce — circumcise. 

Never discard any damaged skin in stitching up 
scrotal wounds — the worst flap will heal. [Warm 
a wound of the scrotum before uniting it with su- 
tures ; it is thus easily relaxed]. 

Always slit the urethra downwards in amputa- 
tion of the penis, and stitch the angles outward. 
This obviates stenosis as far as is possible. 

Always keep a catheter in position continu- N 
ously in injuries to the penis if the urethra be di- 
vided. 

Do not tap a hydrocele without examining the 
position of the testicle with the light. 

Do not strap a testicle without shaving the scro- 
tum. 



GENITOURINARY. 147 

Do not jump to the conclusion that every small 
knot in the epididymis is "tuberculous." Search 
the deep urethra. 

Do not give a decided prognosis of a solid slow- 
growing tumor of the testicle in which hydrocele 
co-exists before you have tapped the hydrocele and 
examined the gland carefully. It may be non-ma- 
lignant. If any doubt exists after this, advise a 
free incision, with permission to excise if neces- 
sary. 



148 GOIvDEN RUI^S OF SURGERY. 



III. Gonorrhoea. 



Never neglect to warn your patient about his 
eyes in treating a "first" attack of gonorrhoea. 

Always warn your patient of the possibility of 
an eruption when giving copaiba for a "first" at- 
tack of gonorrhoea. 

Never neglect in treating gonorrhoeal rheu- 
matism, to cure the discharge as speedily as possi- 
ble. 

Never omit to examine the penis for gonor- 
rhoea or gleet in searching for the cause of a spon- 
taneous knee synovitis in a young man. 

Do not hastily accept the statement of the pa- 
tient that a rash was syphilitic. In inquiring into 
a history, find out whether copaiba was exhibited. 

Never use an injection, unless it be cocaine, if 
there is much pain, scalding or inflammation. 



GENITOURINARY. 149 

Never forget, many gleets are due to slight con- 
tractions of the canal, and may be cured by a steel 
bougie. 

Remember that rest in bed, total abstinence, 
and light diet, together with purgatives and plenty 
of alkaline water, are the best and most rapidly 
successful measures in the treatment of a fresh 
case of clap, together with local cleanliness. 

Never forget that gleet in a patient who has 
had syphilis recently, conveys syphilis. 



150 GOLDEN RULES 01? SURGERY. 



IV. Kidney. 



Do not forget that albuminuria does not neces- 
sarily denote Bright's disease. 

Remember that cases treated for "albuminuria" 
years ago, have been lately proved to have had an 
oxalate stone in the kidney. 

Do not attribute much importance to a painless 
movable kidney if there are no symptoms of kink- 
ing of the ureter. (Frequency of micturition, un- 
satisfied micturition.) 

Remember that all kidney pain is not due to 
calculus ; calculus is rare, whilst the pain of slight 
inflammatory lesions, either primary or ascending, 
is much commoner. 

Always remember that a small percentage of 
renal colic is due to tubercle of the kidney, or ure- 
teral folds or kinks. 



GENITOURINARY. 151 



V. Syphilis. 



Do not adhere to the popular division of "hard" 
and "soft" sores. 

Do not believe or rely upon sharply denned 
rules for the diagnosis of chancre, even with sores 
which are obviously soft and non-infecting, until 
the incubation period (3-5 weeks) is well passed. 
[A so-called "soft" sore may become hard four 
weeks after coition, from having been inoculated 
by a mixed secretion]. 

Remember acquired phimosis is so common an 
accompaniment of the three venereal diseases, — 
acute gonorrhoea, non-infecting sore, syphilitic 
sore, — that you ought never to express a decided 
opinion until you have obtained a look at the 
trouble. 

Do not hesitate to slit up the prepuce in order 
to examine and treat a sloughing sore. If you do 
not do this, the sloughing most probably will. 



152 GOIJ)EN RUIZES OF SURGERY. 

Remember the one simple rule for successful 
treatment of syphilis is, to keep inunction and fu- 
migation method for exceptional cases, and to give 
small doses of mercury more or less frequently, 
but never large doses.* (Hutchinson.) 

Remember the earlier mercury is exhibited, the 
greater the probability that the symptoms will be 
delayed or wholly prevented. 

Never be in a hurry to excise a syphilitic testis, 
however bad, even when there is abscess and fun- 
gus testis ; it will generally heal with patient treat- 
ment. 

Remember in tertiary syphilis whenever a case 

resists the iodide, and whenever it is important 
to obtain a rapid result, that mercury should be 
added to the iodide, or that mercury should be 
given alone. 

Remember syphilis may imitate all known 
forms of skin disease, but it can produce no origi- 
nals. (Hutchinson.) 



*Remember it is better to get aloug with little or even with no mercury, 
because in spite of the strong evidence of experience, it is not proven that 
mercury is a specific.— A. B. C. 



GENITOURINARY. 153 

Never forget that lichen ruber and lichen pla- 
nus are often dusky and copper tinted, and present 
all the features which to those of limited experi- 
ence suggest a confident diagnosis of syphilis 
(Hutchinson). 

Remember that in rare instances syphilis imi- 
tates variola closely; there is, however: 

1. — Persistence. , 

2. — Absence of odour. 

3. — History to guide you. 

Do not sanction marriage in syphilis until three 
years after the date of infection, and then only if 
the patient is free from gleet, and has been thor- 
oughly and successfully treated with mercury. 

Never assume, as was formerly done, that mer- 
cury should be avoided when syphilitic sores ul- 
cerate; on the contrary, when used with iron, qui- 
nine, and opium, it will almost always prove the 
means of cure. 

Do not forget that the safety of the eye in syph- 
ilitic iritis depends mainly upon the promptitude 
and efficiency with which, atropine is employed. 



154 GOLDEN RUI,£S OF SURGERY. 

Never neglect local measures in the lesions ol 
intermediate and tertiary stages of syphilis. 

Remember that a node of secondary syphilis 
usually disappears or is prone to ossify, but a ter- 
tiary node, like other gummata, is more liable to 
suppuration and caries. 

Do not open a syphilitic bubo unless acutely 
suppurating, or a node of bone; they are usually 
absorbed. 



GENITOURINARY. 155 



Therapeutic Hints in Syphilis. 



Always prohibit smoking, and any diet which 
may lead to diarrhoea, while mercury is being 
given for syphilis. 

Never forget that some patients have an idio- 
syncrasy which renders even small doses of the io- 
dides poisonous. 

Never forget that with a patient confined to 
bed and on low diet, ptyalism can be produced with 
half the dose of mercury. [N. B. — Rapid loss of 
weight means that mercury is disagreeing with the 
patient]. 

Remember that mercury is not well borne by 
the tuberculous, the cachectic, or by those having 
chronic renal disease. 

Never neglect to warn your patient about his 
gums and his tendency to catch cold, when taking 
mercury. 



156 GOLDEN RULES OF SURGERY. 

In middle aged and elderly men, continued fe- 
ver with or without night sweats, may be syphilis 
in its late stages and nothing seems to cure except 
KI or the mixed treatment. Try KI alone at first. 



GOITRE. 157 



GOITRE. 



Goitre becomes the object of surgical treatment 
either by symptoms of pressure it causes on adja- 
cent organs, or by altered function of the gland 
which is usually called Basedow's disease. 

In both conditions partial extirpations of the 
growth give brilliant results. Follow Kocher's 
technique and the mortality will be very low. 



158 GOIJ)EN RULES OF SURGERY. 



HAND AND FOOT. 



Do not forget that it is wiser in cases of sup- 
posed needle in hand or foot, when the patient is 
not suffering much inconvenience, not to cut down 
unless the end of the needle is felt. It is wiser also 
not to attempt to remove the needle by its thread; 
the chances are the thread will be pulled through 
the eye, or if it holds, the part above the eye will 
act like a barb. Use the thread as a guide to cut 
to the needle. 

Always radiograph, if possible, foreign bodies 
in extremities, and if you x-ray the hand, mark on 
the plate which hand it is. 

Never estimate the amount of flat-foot when 
your patient is sitting, because in this position the 
weight is taken off the arch, and your estimate will 
be false. 

Do not forget that the foot has been amputated 



HAND AND FOOT. 159 

for supposed tuberculous disease of the tarsus, and 
on subsequent examination the affection has been 
proved to be limited to one of the tarsal bones, 
proving that the patient might have been cured by 
a less extensive mutilation. 

Do not despise or neglect corns, bunions, or ul- 
cers of the leg in the aged or diabetic. They often 
start gangrene. 

Never leave a sprain too long at rest. Pro- 
longed inaction is by far the most frequent cause 
of delayed recovery after injuries of the joints. 

Do not neglect to examine for ataxia before 
treating an ulcer of the sole. But do not diag- 
nose every ulcerating corn to be tabetic. 

Remember that sole, heel, and calf pains may 
mean ataxia, but they often demonstrate a pelvic 
(especially vesico-urethral) or renal focus of irrita- 
tion. ■** 

Never forget that success in the treatment of 
club-foot does not merely depend upon a thorough 
tenotomy. It is gained only by months of careful 
manipulation, massage, and splinting after a thor- 
ough tenotomy has been performed. 



160 • GOLDEN RUIZES OF SURGERY. 

Infections and abscesses of the fingers and 
hand are among the most frequent minor surgical 
lesions you will be called upon to treat, and their 
treatment is so important that I will give a long 
paragraph to it under the heading of the Moist 
Dressing. 

These minor infections such as are known by 
the names of "felon/' "panaritium," "carbuncle," 
"whitlow," "cellulitis," "lymphangitis," etc., often 
lead to major surgical operations and death if neg- 
lected or treated by men who do not properly ap- 
ply the principles on which their treatment rests. 

These infections must be treated by the com- 
bined application of antiseptics and rest. 

The antiseptic remedies cannot do their work 
unless access to the infected parts is given by in- 
cisions and drainage, after which the moist anti- 
septic poujtice and rest by means of long splints 
will lead to the prompt relief of pain and a rapid 
cure. 



HEAD. 161 



HEAD. 



Shave every injured head completely, put on a 
moist pack until ready to operate on it. 

Do not forget that an injury to the head is 
never so slight as to be despised, and never so se- 
vere as to be despaired of. 

Never forget that a blow on one side of the 
skull often produces its main effects on the oppo- 
site side. 

Never close a scalp wound until all dirt is re- 
moved. 

Fill the external ears with cotton, clean out the 
nose, the oral cavity, and purge every head injury 
case. 

Never hesitate to suture contused and lacer- 
ated wounds of the scalp, but in doing so do not 
forget the drainage. 



162 GOLDEN RULKS OF SURGERY. 

Never put stitches deeply into the scalp ; there 
is no reason to wound the tendon. 

If a patient is brought in unconscious, he either 
is drunk, or has a fracture of the skull, apoplexy 
or uraemia. You must make the diagnosis. 

Beware of cellulitis of the scalp when the deep- 
est layer of the scalp has been opened. In such 
cases do not be afraid of incisions, only let them 
run from before backwards, be 2 inches in length, 
and down to the bone. Avoid depletion or depri- 
vation of nourishment, because cellulitis occurs in 
the broken down. 

Never neglect to examine the sub-occipital 
glands as an index to : 

1. — Erysipelas of scalp. 
2. — Pediculosis of scalp. 
3. — Syphilis. 

"Do not carelessly pass the fore-finger through 
the filthy blood-matted hair, and explore at once 
the depths of the wound to ascertain its nature." 
Shave, scrub, ascepticise. 

Do not mistake the depiessed centre of an ex- 



HEAD. lbo 

travasated blood clot, or congenital malformation, 
or atrophy, for depressed fracture; or the sutures 
for a linear fracture. 

Never hesitate to explore, if you are uncertain 
as to whether the skull is depressed or not. Anaes- 
thetize and perform whatever operation is neces- 
sary at once, i. e., as soon as the patient can be 
taken to a hospital. 

Always first examine for fracture of the vertex 
by sight. 

The indications for operation on the skull are : 
To prevent or remove infected tissues, to arrest 
bleeding, to remove the cause of compression, 
blood-clot, depressed bone or foreign matter, to 
provide for drainage, to prevent brain hernia. 

Blood can be wiped from a normal suture line, 
but not from a fissured fracture. 

Remember in trephining the skull that you are 
to consider the bone under your treatment to be 
the thinnest you have encountered, and thinner in 
one half of the circle than the other. 

Remember that the more a fracture of the skull 



164 GOLDEN RULES OE SURGERY. 

approaches the punctured form the greater the 
need for elevation. 

Remember there never is uncertainty as to the 
proper treatment of gunshot-wounds of the skull 
in ordinary civil practice. They should be invari- 
ably operated on, the wound of entrance being al- 
ways comminuted and depressed. 

Never fret about the periosteum or pericran- 
ium. Sacrifice it without hesitation if you find it 
infected or torn, or lacerated beyond capability of 
repair. . ' "• 

I have discarded large trephines and think that 
much more satisfactory work can be done with the 
smallest trephines and the Gigli saws. In most 
cases the chisel and rongeur will do all that is 
required. 

Always remember it is better policy to remove 
fragments of bone whose vitality is uncertain. 

Remember that injuries of the skull, when lim- 
ited to a small area, demand active treatment. 

If actual depression exists, whether the fracture 
be compound or not, operation is a necessity. 



HEAD. 165 

Compound injuries of the skull indicate imme- 
diate operation. 

Never neglect to watch the temperature in com- 
pression. It is a more reliable guide in prognosis, 
than conditions of consciousness. [If the temper- 
ature be sub-normal and should subsequently rise 
high, prognosis is bad]. 

Remember that the operation for the removal 
of fragments which have been pressing on the 
brain is rarely complete, spiculae being often left 
behind. 

Never undervalue the use of calomel in head 
injuries. The old experience still holds good that 
the physician who purges most of his patients has 
the best results and the largest practice. It took 
me twenty years to find this out, and let me say 
that calomel is not the only purgative. Castor oil 
and salts are better in most cases; even the enema 
may suffice. 

The removal of the Gasserian ganglion is so 
serious an operation, its mortality so high, its re- 
sults so uncertain, even in the hands of good young 
surgeons (men over forty do not seem to perform 
the operation often), that I do not think it will be 



166 GOI^DEN RULES OF SURGERY. 

clone so frequently in the future as it has been in 
the past. A case reported as successful, walked into 
the Lutheran hospital with return of tic in its 
worst form little more than ten months after the 
ganglion had been removed( ?). 

Always do peripheral neurectomies without the 
cranial cavity on the affected branches of the trig- 
eminus. The relief given will last for several years 
if long pieces of the nerve are resected, and may 
be permanent. These are beautiful surgical oper- 
ations requiring great skill and they neither put 
out an eye, nor do they kill. 

As a last resort the extirpation of the Gasserian 
ganglion may be done. I advise referring the cases 
to younger men who are well trained, who want 
the experience and who are glad to get big cases. 
The results will be likely to cool their enthusiasm. 

Brain tumors have become the objects of sur- 
gery in late years, and there have been some bril- 
liant results. But in the vast majority of cases the 
benefit to the patient is in no way up to the bril- 
liancy of the surgical achievement. 

Sometimes a little relief js derived from the 
mere elevation of portions of the skull. I have 



HEAD. 167 

made blind patients see by elevating and removing 
a part of the frontal bone and large masses of un- 
derlying tumor and brain tissue. The benefit only 
lasted a few months when the headache and blind- 
ness returned. 

I consider any surgical operation which offers 
a reasonable chance to benefit the case, if only for 
a short time, justifiable. I am of the same opinion 
regarding operations in malignant tumors of other 
parts of the body as well, and this opinion will hold 
good as long as no better method of treatment is 
found. These desperate operations, however, 
should not be undertaken without having a full un- 
derstanding with the patient and his friends, and 
only after consultation with other members of the 
staff. An occasional life saved must be recompense 
for many fatal and discouraging results. 

The results of the treatment of cancer by the 
x-rays have been bad. Only in superficial epi- 
thelioma, where the red-hot iron would have done 
as well, have I seen benefit. 

In sarcoma I have seen some results that 
looked miraculous. But may they not have been 
gum mat a? 



168 GOLDEN RULES OF SURGERY. 



HERNIA. 



Remember that no age is too young for a truss, 
and that no hernial protrusion should be without 
one. 

Never prescribe for a case of vomiting without 
enquiring about hernia and examining the abdom- 
inal rings. 

Do not diagnose a "strangulated" hernia in the 
male without first feeling for each testis, as inflam- 
mation of an undescended testicle often simulates 
strangulated bowel very closely. 

Always "explore" in cases of persistent vomit- 
ing if a "lump," however small, is found occupy- 
ing one of the abdominal rings and its nature is 
uncertain. 

Never be satisfied that the gut is reduced by 
taxis until you have put your finger fairly into and 
through the ring, nor until you have ascertained 



HERNIA. 169 

by comparison of the two sides that no unnatural 
fulness is left. 

Remember that vomiting may continue after re- 
duction of gut by taxis, and be due to paralysis of 
the loop from its tight constriction, or it may be 
due to the hernia having been reduced en masse. 

Never be deceived by an opiate masking the 
acute symptoms of hernia, obstruction, peritonitis. 

Never procrastinate in strangulated hernia. It 
is the rule that the operation, if done promptly, will 
prove successful in herniotomy; the danger lies in 
your allowing the bowel to become irrecoverable. 
If you are in doubt, operate. 

Remember it is criminal to neglect a strangu- 
lated hernia — if you cannot reduce it, and dare not 
operate, hand the patient over to some one more 
competent. 

Do not hesitate to return the gut in herniotomy 
in all stages of disease short of gangrene. 
Use warm water to irrigate the gut and see it 
change from dark blue or black to red or pink be- 
fore you return it to the abdominal cavity. 



170 GOLDEN RUIZES OF SURGERY. 

Do not hesitate to give a saline purge the day 
after the operation, no matter how badly the bowel 
seemed to be injured. The same rule holds good 
after a resection and an end to end anastomosis. 
There is no danger of perforation or giving way 
of the suture as a result of the administration of 
castor oil or Epsom salts. But there is danger of 
high fever from autointoxication by the absorp- 
tion of foul intestinal contents and of death if the 
sewers are not promptly cleansed out after stran- 
gulation. Whenever possible let some form of 
radical cure operation follow the operation of her- 
niotomy. If not done at once it will have to be 
done later. 

The principle upon which the radical operation 
for the cure of hernia rests, may be stated as 
follows : Hernia takes its origin in the abdomen 
and is caused by pressure from within the abdo- 
men; it must be cured by attacking the starting 
point. This is always the so-called inner ring. 
All operations or parts of operations upon the 
outer ring or the superficial parts of the inguinal 
canal are wrong in principle, and no matter how 
ingenious and beautiful the method, if it attacks 
the middle or outer layers of the abdominal wall, it 



HERNIA. 171 

will be futile, a waste of energy and will fail in 
achieving a radical cure. 

The work that counts must be done on the ab- 
dominal wall just above the inner ring. The inner 
ring must be abolished. A neat and safe way to 
do this is by Kocher's new operation of inverting 
the sac. See the last edition of his operative sur- 
gery, the best book of its kind ever written. It gives 
a clear description of this simple method. Chas. 
Mayo also does this work at the inner ring high 
up on the abdomen and has realized the uselessness 
of work on the outer layers of muscle and fascia 
or the skin. 

I do not wish to be understood as advocating 
no suture of the middle and outer tissues. I think 
they should be brought together as neatly as possi- 
ble so as to get primary union. But I maintain that 
for the end of achieving radical cure this work is 
of very little aid to the stitches made high up 
which close the inner ring. Were it not for the pur- 
pose of rapid healing and avoiding suppuration the 
outer layers might be left to heal by granulation. 

Bernhardt, a former assistant of Kocher's, 
now the leading surgeon in the Engadine, in those 



172 GOLDEN RULES OF SURGERY. 

cases of large hernia in which it seems desirable en- 
tirely to close the inner ring, simply drops the tes- 
ticle into the abdomen, thus enabling him abso- 
lutely to obliterate the canal, by having no sper- 
matic cord passing through the abdominal wall. 
Tht same object could be got at by castration, 
but ] night be objectionable to some patients. 

In the radical cure of umbilical hernia the best 
results follow the transverse incision and the over- 
lapping of broad, flat flaps of fascia, as published 
by W. H. Mayo. In these hernias there is no inner 
and outer ring. They are direct hernias and have 
practically but one ring. 



173 



"If you would serve your brother, be- 
cause it is fit for you to serve him, do not 
take back your words when you rind that 
prudent people do not commend you." — 
Ralph Waldo Emerson. 



"INFLAMMATION," AWAY WITH THE 
WORD AND THE CONFUSION IT ' 
HAS CAUSED. 



I have thought for many years that there is 
no real or srenuine inflammation without infection. 



& 



When the best pathologists like Ribbert,* Wei- 
GERT and Ehrlich are in constant controversies 
and polemics about inflammation, what are we sur- 
geons to do about the problem ? 



*Eibbert declares, in his late publications, that there is no such thing as 
parenchymatous inflammation. They will probably all drop the time- 
honored but perplexing word, inflammation, and speak of it, in the literature 
of thi future reverentially, as of a thing dead and buried. 



174 GOLDEN RULES OF SURGERY. 

It is clear to all surgeons that between the pain- 
less and afebrile regeneration of injured tissues, 
and the restless, painful and febrile fight for exist- 
ence and restoration to health, there must be very 
many intermediate stages. In fact there must be 
all degrees of septic inf^ctJ°n, up to the ones that 

end in death. 

* 

Throwing all of these very different processes 
together seems to be the cause of the existing con- 
fusion. 

The mistake was made before we had any 
knowledge of infection and the term Inflammation 
was made to cover the whole. 

I know that it is more difficult to cure old 
chronic and well established ills than acute fresh 
ones. After a long painstaking treatment has fail- 
ed, a radical operation is done as a last resort. 

I should like to propose that by common con- 
sent we drop the word inflammation. It has done 
some good, but has caused much confusion. Its 
various stages and its confounding definitions make 
of the word a cloudy notion and it seems unser- 
viceable. Let us extirpate it ! 



175 



Inflammation and leucocytosis are looked upon 
as reactions by Ribbert,* who pronounces them 
as "under all circumstances defensive processes." 
He says that they are characteristic of increased 
normal life processes. 

A wound incised or punctured will heal by tis- 
sue regeneration and without pain unless infection 
intervenes. 

Infection causes tissue-unrest; regeneration is 

thus nearly always interrupted and there is pain, 
etc. 

After the tissues have eliminated, absorbed or 

in some way disposed of the noxious unrest-produc- 

'ing materials, be they bacteria, toxines or what 

not, regeneration again goes on to its normal end. 

If the tissues can not rid themselves of the sep- 
tic materials which produce fever and pain, the 
moist pack, or better, drainage by incision must 
provide for their escape ; then again the healing pro- 
cess, will be resumed, the unrest in the tissues is 
stopped and also the pain. 



*Elbbert: Die Bedeutung der Entzundung — published by Cohen, of Bonn, 
1905. Brochure, price 35 cents. 

If Ribbert is correct, and I think he is, then inflammation must be com- 
pletely separated from infection, because the latter is always offensive, often 
deadly. It is certainly opposed to normal life processes. 



176 GOLDEN RULES OF SURGERY. 

Let us substitute the simple, clear terms' of in- 
fection and its concomitant tissue-unrest* for in- 
flammation. , 

Away with inflammation! I feel as if this 
thought were in the surgical atmosphere and that 
it will be shared by many surgeons and also by 
many clear-headed pathologists who can break 
away from traditions, although hallowed by such 
names as Virchow, Cohnheim and others who 
worked before bacteria were recognized as the 
chief cause of infectious diseases. 

Let us separate the benign and defensive pro- 
cesses sharply and finally from the offensive ones. 
If the pathologists can not get along without in- 
flammation, I think we practitioners of surgery 
and medicine can, and with profit to our under- 
standing of disease. 

I am convinced that the process of regenera- 
tion, by which is meant the normal healing process, 

never goes beyond its object unless an infection in- 
tervenes. 



*This word tissue-unrest is used for the first time in this little 
book. It seems to me to express exactly what I mean. "May it have a 
smooth passage and find favor in the eyes of students. 



177 



The small round cell infiltration also never 
goes into febrile and suppurative processes unless 
infection takes place, which may produce the worst 
form of tissue-unrest and change a restful defen- 
sive process into a process of effusion, unrest, pain 
and fever. 

I propose that we separate Regeneration and 
Leucocytosis without fever, from Infection, Toxae- 
mia and Suppuration. (Sepsis.) The pathologists 
have mixed up these clear processes into the notion 
of inflammation. This subject is now and has al- 
ways been turbid, muddy, and therefore a favorite 
field for discussion at country medical meetings as 
well as at the centers of pathological science. The 
word inflammation makes for confusion. Away 
with it now and forever !* See general considera- 
tions, pages No. 59, 60, and 61. 



*"Der Mohr hat seine Schuldigkeit gethan, der Mohr kann gehen." Schiller's 
'Fiesco." (The Moor has done his part, the Moor can go.) 



MM 



178 GOU)EN RULES OF SURGERY. 



MOIST DRESSING." 



There has been much discussion as to the rela- 
tive merits of the moist or dry dressing for wounds 
or incisions which appear to be clean or aseptic, 
and can therefore be completely closed b'y suture. 
Many maintain that after an aseptic operation in 
which the skin can be closed by sutures, a dry 
dressing will be the most appropriate and give the 
best result. I grant you that theoretically this is 
true, and that it works well in the majority of 
cases, but I maintain that it is impossible to say 
of any operation that it has been absolutely aseptic 
or that there will not be a stitch abscess or some 
other kind of an infection. This being the case, I 
favor the moist dressing in all cases, for the reason 
that under a moist dressing stitch abscesses or 
other superficial infections will be almost painless 
because the pus will be absorbed by the moist 
dressings into which it can escape. This is not the 
case if a dry dressing is used. The moist dressing 



179 



will thus avoid much pain and many a change of 
dressings that would be needed under a dry dress- 
ing. 

The moist dressing is one that may be aseptic, 

wet by the use of sterile water or it may be as 
antiseptic as is desirable by the use of antiseptic 
solutions. The moist dressing may be allowed to 
remain in situ as long as seems desirable, the only 
proviso being that its moisture or "wetness" be 
insured by the prevention of evaporation. This is 
the practically important point. Many wet dress- 
ings are applied carelessly and in a few hours be- 
come dry dressings. A properly applied wet dress- 
ing must remain wet any length of time required. 

To insure the indefinite moisture of a dressing 
a little care in the application of the rubber tissue 
oiled silk or other material which must cover 
each and every moist dressing is necessary. This 
consists in making sure that the impermeable oiled 
silk or rubber, tissue is larger than the moisture 
bearing gauze, cotton or other poultice. If any 
part of the moist gauze protrudes, the dressing will 
not be moist long, because evaporation and osmo- 
sis soon dry it. 



180 GOLDEN RULES OF SURGERY. 

The greatest benefit of the moist dressing or 
antiseptic poultice as it has been called, is seen in 
cases of infection of the extremities, because in 
these localities rest by means of splints or even 
the plaster of Paris casts over and above a moist 
dressing can be given, thus insuring drainage and 
rest to the infected parts, the two cardinal indica- 
tions to be fulfilled in infections. A properly ap- 
plied dressing of this kind may be left untouched 
for a clay, a week, or a month, or even longer. 

I have often applied this kind of dressing to a 
crushed limb, a compound comminuted fracture, 
and have allowed it to remain for six weeks or un- 
til union was complete. It is true that in some of 
these cases the dressings when removed were 
often very odoriferous, but the patients had made 
afebrile, satisfactory recoveries, the odor being due 
to saprophytic or non-pyogenic bacteria. The 
wounds having been perfectly drained were found 
granulating as normally as if they had been dress- 
ed every day. 



MOUTH. 181 



MOUTH. 



Do not leave hare-lip pins in hare-lip operation, 
(if you use them), longer than forty-eight hours. 
Your plastic operations on the lips will do better 
by using fine thread or catgut than the old-fash- 
ioned needles. The use of needles is rapidly pass- 
ing. Remove sutures early. By needles I mean 
insect needles or long pins. 

Always stop to guard your thumbs before you 
reduce a dislocation of the jaw. 

Always use blunt scissors in operating on the 
fraenum linguae. 

Do not forget in ranulae to search for stone in 
the duct. 

Never think lightly of any ulcer on the tongue 
or lips of a patient after middle life. 

The differential diagnosis between syphilis and 



182 



GOLDEN RULES OE SURGERY. 



malignant disease of tongue, floor of the mouth, 
jaws and pharynx is difficult. Always try an anti- 
syphilitic course of treatment, together with local 
measures before making a radical extirpation. 
Four or six weeks will suffice to exclude lues. 

Always look for bad teeth and send the patient 
to a good dentist before you begin your treatment. 
Many cases of stomach disease are due to decayed 
and defective teeth. 

The old rule, upper lip syphilis, lower lip epithe- 
lioma, will not always do. 



NOSE. 183 



NOSE 



In. nose bleeding of a serious nature or long 
duration, don't fool away time with ergot, adren- 
alin or other medicines. Plug the nose and do so 
effectively. 

Always suspect a foul discharge in a child to 
result from a foreign body, if the discharge be 
from one nostril. 

Never neglect the mouth ligatures of the plugs 
for the posterior nares. It is difficult to remove 
these plugs without them. 

Never forget to look for Meyers' pharyngeal 
tonsil in mouth breathers. Its removal is one of 
the most satisfactory surgical operations. 

Nil nocere should be the motto of every spec- 
ialist who finds "spurs" in many peoples noses 
and saws or gouges them away. Scars on the mu- 
cous membrane in the nose are covered by scabs, 



184 



GOLDEN RULES OF SURGERY. 



and are often troublesome for years. The same 
motto is also very much to be recommended to G. 
U. men who do internal urethrotomy for stricture 
and gynaecologists who think every woman ought 
to be curetted annually, as well as to other spec- 
ialists and general practitioners ; and last but not 
least let surgeons keep the old motto always in 
mind. 



OESOPHAGUS. 185 



OESOPHAGUS. 



Never forget that when a foreign body, though 
only of moderate size, has become fixed in the 
commencement of the oesophagus or the pharnyx, 
and has resisted a fair trial for its extraction or dis- 
placement, an incision, (pharyngotomy), etc., 
should be made at once and the foreign' body 
should be'removed, although no urgent symptoms 
are present. 

Never omit to exclude aneurysm of the aorta 
before you pass a bougie for supposed stricture of 
the oesophagus. 

Never use force in passing a bougie through 
any oesophageal structure, certainly never in ma- 
lignant stricture or where there is any suspicion 
of aneurysm. 

Remember catgut sutures are used for wounds 
of oesophagus ; never silk or silver. 



186 



GOLDEN RULES OF SURGERY. 



Always be certain that your tube enters the 
oesophagus in using the stomach pump (especially 
if the patient be under chloroform, comatose, or 
drunk.) [Cases are recorded in which beef tea, 
plaster of Paris, and other fluids have been injected 
into the lungs with fatal results]. 

Oesophagotomy is easy, if the surgeon can 
make the tube bulge on the neck by using a large 
sterile male catheter introduced per os. 

Stricture of the oesophagus caused by swallow- 
ing concentrated lye kills about two-thirds of the 
children to whom this accident happens. The 
other third survive with strictures of various por- 
tions of the gullet and pharynx due to cicatricial 
contractions of all degrees, up to complete closure 
of the passage. In many of these cases life is saved 
by feeding through an artificial opening into the 
stomach made by the operation of gastrostomy. 

In a case of this kind a child was kept alive, but 
was puny, weighing only 19 pounds at the age of 
6 l / 2 years. She had been kept alive four years by 
feeding through the artificial fistula leading into 
the stomach, but was evidently growing weaker all 
the time. No doubt the mucous membrane of the 



OESOPHAGUS. 187 

stomach was partially cauterized away, and the 
fistula was leaking- constantly and was not working 
satisfactorily. Death would surely have ensued if 
the condition had not been remedied. 

Not even the finest bougie could be passed, nor 
could colored fluid or milk be injected either up- 
wards or downwards through the stricture. Un- 
der these circumstances I determined to attempt 
forcing a passage through the posterior medias- 
tinum. 

As a preparatory operation I made an oesoph- 
agotomy at the root of the neck, thus shortening 
the distance from the oesophageal opening in the 
stomach to a point just above the manubrium 
sterni. My intention was to bore a hole with a tro- 
car-pointed instrument through the posterior med- 
iastinum, and below follows a description of what I 
found and did. I shudder even today at the fear- 
ful chances I took to save a life. When it is re- 
called that in the dark, the trocar had to pass 
through cicatricial, irregular masses of tissue in 
close relation to the arch of the aorta, the left 
common carotid, the thoracic duct, the two pneu- 
mogastric nerves and many other important struc- 
tures, among them many thin walled veins, the pos- 



188 GOLDEN RULES OF SURGERY. 

terior wall of the trachea, etc., the hazardous na- 
ture of this operation may be appreciated. I am 
told that Prof. Warren cited this operation to a 
class of his students at Harvard medical school as 
among the most daring ever undertaken. I am 
sure I have never done one that was more uncer- 
tain in its outcome. I am glad to report that the 
patient's weight increased from 19 to 42 pounds in 
a short time after the operation was done. I am 
told that she still uses bougies, but has become a 
fairly healthy young lady. 

Second Operation. — Three weeks after the first 
operation a second one was performed for the re- 
duction of the stricture, which was now much 
more accessible, the patient's condition being about 
as good as when first operated upon. When she 
had been chloroformed, the end of a soft rubber 
tube, whose other extremity was attached to a Da- 
vidson's syringe, was passed through the epigas- 
tric fistula into the gastric opening of the oesopha- 
gus. Pressure was applied to the bulb, but no 
water appeared at the fistulous opening in the neck; 
All attempts to inject water through the stricture 
from either side had utterly failed. A pillow was 



OESOPHAGUS. 189 

placed under the shoulders and the neck put upon 
the stretch. 

The index finger was introduced into the oeso- 
phagus through the opening in the neck, a soft 
metal bougie being at the same time passed into 
the lower portion through the cardiac orifice ; at 
first the end of the bougie could not be felt by the 
examining finger, and much careful manipulation 
was necessary before it could be positively deter- 
mined. -The uncomfortable proximity of impor- 
tant vessels precluded the use of any cutting in- 
strument. The pewter or block tin bougie was 
then removed and its end cut to a trocar point with 
a scalpel and reinserted as before; when located, 
gentle manipulation was made against its point 
through the stricture by the index finger in the 
oesophagus, a rotary movement being simultane- 
ously given to the bougie. In this manner the 
stricture was successfully perforated; the bougie 
passed upward to the opening in the neck, where 
a stout double silk ligature was attached to its end 
and drawn down through the oesophagus and out 
of the artificial opening in the stomach. Upon this 
ligature there was threaded through its lumen a 
Nelaton rubber catheter of an external diameter 



190 GOU)EN RUUSS 0£ SURC^RY. 

of 1.5 centimeters; this was drawn through the 
oesophagus until the upper end had entered the 
neck, and then pushed upward until the upper end 
could be seized in the pharynx and drawn forward 
out of the mouth; both ends of the catheter were 
now outside of the patient's body; they were su- 
tured to the ligature, the ends of which were tied 
together. 

The after treatment was troublesome and it was 
not easy to keep open the passage. In order to 
keep it open regular, continued use of bougies was 
necessary. Without their use the canal would 
surely have closed. See New York Med. Journal, 
Vol. 1895 for details. 

I have often been asked by students and phy- 
sicians what operation during my long experience 
I considered as the greatest and the one requiring 
most "nerve." I always answer that a surgeon 
who operates on his nerve is a dangerous man and 
not well qualified. The quality called "nerve" by 
Americans and English should not be required, in 
fact is not a valuable asset in a well-educated sur- 
geon. However, let us remember that it takes a 
lot of nerve even to puncture the pleural cavity 
or to make an abdominal puncture or tapping op- 



OESOPHAGUS. 191 

eration in a case of dropsy if the surgeon has not 
the anatomical and physiological training. Nerve 
is valuable to a surgeon if it means courage to do 
his duty, which he has recognized after exhausting 
all scientific methods of diagnosis and after his 
judgment says : Take the risk because it seems 
likely to prolong or save a life or to palliate other- 
wise fatal disease. In the above case my judgment 
was proven to be correct and my courage rewarded 
by the favorable outcome of the case. I have never 
had one requiring more "nerve." 



192 GOIvDKN RUIvES OF SURGERY. 



operations: 



Remember that "surgical cleanliness is more 
than ordinary cleanliness." 

Have plenty of assistance, but not too many as- 
sistants. 

Never permit a naked light to be brought near 
the ether apparatus when anaesthetising. 



Be sure that nurses are reliably trained in asep- 



sis. 



Never neglect in all operations which will pro- 
duce a shock to the urinary system, e. g., varico- 
cele, fistula, piles, radical cure of hernia, to ascer- 
tain before the operation, if the urethral canal be 
without stricture. [Sometimes stricture is encoun- 
tered in relieving retention after such operations, 
and you may, be unprepared for the obstruction.] 

I approve of spectators, but they must obey 



OPERATIONS. 193 

rules that are made to insure cleanliness and avoid 
dangers. 

Never neglect to examine the lungs for phthisis 
in all cases of ischio-rectai disease and fistula in 
ano. 

Always see that the end of the plug or drain is 
properly secured, in inserting plugs or plug-appli- 
ances for colotomy and gastrostomy; or drainage 
tubes for abscesses or wounds, especially in empy- 
emata. 

Never operate without first examining the urine 
for albumin and sugar, but do not, in these aseptic 
days, be scared about either, if the operation be a 

necessity. 

# 

Remember cases of jaundice and those with dis- 
ease of spleen are unfavorable subjects for opera- 
tion. 

Never apply an elastic (Esmarch) bandage to 
render a limb bloodless if tuberculosis or growth 
or gangrene is present. Elevate the limb, stroke 
it, and apply the Esmarch rope. (L,isT£r.) 

Never forget a patient's age in years is not the 



194 GOLDEN RULES OF SURGERY. 

index to his "vis" or "last." Vide Errors in the 
Chronometry of Life, Paget, Studies of Old Case 
Books. 

Read : Paget on Surgical Disasters and Hilton 
on Rest and Pain, buy Senn's Principles of Sur- 
gery and KochEr's Operative Surgery. The latter 
is not an ordinary text-book, but is based on Koch- 
Er's own work. He recommends nothing unless he 
himself has found it to be useful in practice. Un- 
fortunately I can not recommend a text-book cov- 
ering the whole of systematic surgery because no 
one man has written a book which will be found 
equally good in all parts. Where a system of sur- 
gery is written by many different authors and con- 
tributors, there are always some weak and care- 
lessly written chapters, partaking of the nature of 
compilations, made without research or large ex- 
perience on the writer's part. Men try to do too 
much and are often, persuaded by publishers and 
prompted by a desire or a promise to make money. 
College professors are apt Lo write books knowing 
that their students will buy them. Let the stu- 
dents buy them, but don't you. 

Never forget that the surgeon who neglects to 



OPERATIONS. 195 

suture a divided nerve or tendon commits the 
same mistake as he who neglects to reduce a frac- 
ture. [Use an ordinary sewing needle, with a round 
point, for nerves]. 

Never forget the tripod of successful healing of 
wounds has three legs — asepticism — rest — coapta- 
tion of edges. 

Never forget that if an operation wound suppu- 
rates, the fault lies with the operator or his as- 
sistants. 

Remember that mercury perchloride gauze or 
lotion ruins steel instruments. 

Rapidity is a desirable quality in an operator 
for more reasons than one; the quicker the opera- 
tion is finished the shorter will be the time of the 
narcosis, a great advantage for the patient; still 
let there be no lack of exactness and of artistic 
finish. 

The neatness of the dissection will be greatly 
enhanced by the free use of retractors for the pur- 
pose of exposing the field. A good operator rec- 
ognizing the anatomical structures will work by 



196 GOLDEN RULES OF SURGERY. 

layers and I advise using the fingers and scissors 
more than the knife after the skin-incisions. 

A bad anatomist can be a reckless butcher, but 
not an artistic surgeon. 

Remember that an intimate knowledge of the 
physiology of respiration, of circulation and of 
blood pressure are as necessary to make a success- 
ful operator as is anatomy. This may sound par- 
adoxical, but I never fail to impress upon my stu- 
dents the great value of operations and 'vivisections 
on large dogs. 



PEXvis. 197 



PELVIS. 



Remember in extravasation of blood beneath 
the gluteal fascia there is rarely any bruise or sign 
of injury to the skin. Do not mistake such for an 
abscess. 

Never forget to determine the absence of a for- 
eign body in buttock wounds. 

Always ligature a bleeding vessel in the but- 
tock at once, even at the risk of a deep dissection. 

Do not carry out passive movements very ac- 
tively in fracture of the true pelvis in order to elicit 
crepitus. Remember the serious consequences 
which may ensue from the displacement of a 
pointed fragment. 

Never omit to empty the bladder (if the patient 
cannot) in cases of falls on the buttocks, fractured 
pelvis, blows on the belly, etc. 



198 GOLDEN RUL£S OF SURGERY. 

In many of the headaches and pelvic aches of 
women, purgation actually cures. 

Retroflexions of the uterus are not often indi- 
cations for surgical interference. 



RECTUM. 199 



RECTUM. 



Never forget in fistula in ano to eliminate for- 
eign body, ulceration, stricture, and malignant dis- 
ease of the rectum. 

Never forget that constipation alternating with 
diarrhoea renders a rectal examination for stric- 
ture imperative. 

Remember the saying, "No internal opening to 
a fistula, or a blind fistula, is usually a blind sur- 
geon." 

Do not forget the probable need for a catheter 
after an operation on the rectum. 

A patient who thinks he has piles may have 
something quite different. An enema followed by 
an examination will permit you to make a diag- 
nosis in some cases, in others anaesthesia will be 
necessary. 



W 



200 GOLDEN RULES OF SURGERY. 



SHOCK. 



Never forget in shock and collapse that the es- 
sence of successful treatment is to obtain time for 
your patient to rally. Keep the heart going, but 
do not trade on its exhausted power; maintain its 
action, do not force it. 

Do not resort to strychnine, digitalis and other 
poisons, but if you must inject something, try a 
syringeful of ether; if you will give poisons, give 
them before the heart and diaphragm are too weak 
to stand the dose. 

Many patients are killed in shock by the syringe. 
Some survive in spite of the poisons that are used, 
but I have never seen one benefited by them. 

Remember that minimum doses suffice to kill a 
patient in shock after an operation, or after a loss 
of blood. 

Warmth applied to the surfaces, salt solution 



SHOCK. 201 

infused, liberal rubbing, artificial respiration and 
similar therapy are helpful; electric stimulation 
lowering the head and elevation of the legs are 
often called for, but hypodermic use of poisons, 
is not permitted in my service. I would have the 
tablets and syringe barred from the operating 
room. I would rather honestly sign a certificate : 
death from "shock, following operation," than 
doubtingly write those words after a lot of poisons, 
two, three or four different kinds, had been shot 
into a moribund patient by a scared lot of surgeons, 
assistants and nurses. 



202 GOLDEN RULES OF SURGERY. 



SPINE. 



Never forget that in fracture of the spine the 
tendency to death is due to pneumonia and com- 
plications, if the fracture is situated high up; and 
to urinary inflammation and bedsore, if lower 
down. 

Of 500 cases operated on by laminectomy or 
some other operation for the purpose of releasing 
the compressed cord, one half survived. 

Of three hundred cases with more definite his- 
tories only twenty-nine per cent, were restored to 
health. 

But you must remember the unreliability of 
statistics in surgery. Always have a careful neu- 
rological diagnosis before deciding to operate. 

Never forget the atonic bladder or the back, 
devoid of the sense of feeling. 



spins. 203 

Do not be content with merely washing the red 
rubber catheter each time you use it. Let it be 
kept in carbolic lotion. 

Remember also that the urethra is insensitive, 
and that the catheter must be introduced with 
double care and treble gentleness. 

Never neglect to see for yourself that the 
patient's back is kept clean, dry and well protected 
from prolonged pressure. Assistants and nurses 
usually do their duties, but see for yourself. 

'Never puncture a spina bifida in the median 
line, always at the side, taking in the skin; avoid 
air, and close puncture securely. 

Spina bifida may often be safely removed if the 
surgeon is expert and aseptic. 

Never suspend by the head alone in adjusting 
a Sayre's jacket for a Pott's curvature of the spine ; 
let the toes and armpits help to support the weight. 

Never forget how easily pressure sore or ec- 
zema occurs under a badly padded or dirty plaster 
of Paris jacket. It is better to remove it more 
often than have this happen. 



204 GOLDEN RUI,ES OF SURGERY. 

Never forget that the earlier stages of caries 
are often unaccompanied by any decided symp- 
toms. When curvature exists there is no longer 
room for doubt, but do not wait for curvature. 

Never permit a patient who has sustained any 
injury to the back to quit the casualty department* 
until he has passed water. [Bloody urine will 
show at once that the kidney has been injured]. 



*Emergency ward. 



STOMACH AND INTESTINES. 205 



STOMACH AND INTESTINES. 



Our operations for cancer of the stomach have 
been unsuccessful if we refer to a radical cure of 
the disease. Very few permanent cures are record- 
ed. Cancer of the stomach is so very common and 
causes so much distress that these cases will al- 
ways continue to apply for relief. Our only hope 
of ever curing cancer of the stomach lies in early 
diagnosis. It is probably true that there is a pre- 
cancerous ulcer in most cases and if this stage i e 
diagnosed and treated by a drainage operation the 
ulcer will heal up,- and a cancer be avoided. Many 
lives can be saved by an early gastroenterostomy 
or gastro-duodenostomy if only the operation be 
done during the early stage of an ulcer. 

As long as the medical treatment of cancer 
shows a mortality of one hundred per cent, it is 
clearly the duty of the internist to refer cases 
which resist his treatment and in which the well 



206 GOU)EN rui.es of surgery. 

posted physician must suspect malignancy, to a 
surgeon as early as possible. 

A look into the future seems to indicate that 
the medical man must become a scientific patho- 
logist and diagnostician if he would rise above the 
level of the charlatan. The function from which 
he will derive most glory and most income, because 
it will be the most beneficial to the patients, will be 
the timely calling of an operator. It will be a dis- 
tinct step forward, if the internist will be as ready 
to prescribe a surgeon for his cases as he has been 
to prescribe morphine or other drug in the past. 
The public will learn to appreciate this service and 
to pay for it gratefully, if only the surgeon be 
honest and unselfish enough to say to the patient 
upon whom he has successfully operated : "You 
owe your life to your physician, who so skillfully 
recognized the danger you were in." 

Few ulcers make diagnosable symptoms unless 
they are indurated. Their symptoms are of the 
kind which indicate stenosis at the pylorus and ob- 
structed drainage of the food from the stomach into 
the duodenum or from the duodenum into the je- 
junum. I have seen painful pyloric spasms in some 



STOMACH AND INTESTINES. 207 

of these cases and regard this symptom as of great 
value in making a diagnosis of ulcer. These 
spasms last from a few minutes to an hour and are 
very painful. They not only involve the pyloric 
ring in the painful contraction but the entire py- 
loric end of the stomach is involved as I have been 
able clearly to prove in several cases occurring in 
medical men and other very intelligent patients fa- 
miliar with the anatomy of the stomach. It is clear 
to my mind that only this early drainage operation 
of the stomach will ever succeed in curing or 
rather avoiding cancer of the stomach. 

Operations of resection of -parts or the whole 
of the stomach are usually fatal or at best only 
prolong life for a short time. The best result I 
have ever had, was that of a woman from whom I 
removed the pyloric half of the stomach who now 
lives in fine health, more than four years after the 
resection. All my other cases of resection, amount- 
ing to fifty-eight in all, died of cancer in less than 
three years. Some of them were relieved, and 
even gained weight for months, but all eventually 
succumbed to the disease, eleven died of shock. 
This experience accounts for my pessimism as re- 



208 GOLDEN RULES OF SURGERY. 

gards radical cure of cancer of the stomach by 
surgical operation. 

The successful surgery of the stomach is con- 
fined to cases of benign or precancerous ulcers, 
and has been much to the front for about two years. 
The operation which gives us our most pleasing 
results is gastroenterostomy above referred to, 
and in this short treatise I can only give a few 
rules which can be followed with safety. 

Remember to make the anastomosis between 
the stomach and the intestine so as completely to 
drain the former and to give the ulcer physiologi- 
cal rest, under which it will nearly always heal, if 
benign. 

Remember that the so-called vicious circle can 
be avoided by Kocher's gastro-duodenostomy or 
by gastrojejunostomy without a loop. Make the 
anastomosis not more than three or four inches be- 
low the duodenum in the first part of the jejunum 
so as to avoid a loop. 

I made a posterior gastroenterostomy and 

found that the indurated ulcer which extended into 
the pancreas failed to heal. We can not promise 



STOMACH AND INTESTINES. 209 

to cure every case. The resection of the ulcer 
itself (of course I am speaking only of benign ul- 
cers), may prove to be the only method of radical 
cure in some rare cases. 

I once resected a tumor (the microscopical ex- 
amination failed clearly to establish malignancy), 
of. the pancreas the size of a small hen's egg. In 
doing so I cut the duct of Wirsung. I did the thing 
that occurred to me at the time of the emergency. 
I split open a neighboring loop of jejunum and 
stitched the edges to the pancreas in such a man- 
ner that all of the wound in the pancreas opened 
into the gut. The patient, a woman of 70 years, in 
whom I had diagnosed pyloric cancer and was in- 
tending to resect, lived six weeks. An autopsy 
was refused and the cause of death in the abscence 
of a more definite diagnosis was given as exhaus- 
tion. 

Operations for the removal, of foreign bodies 
from the stomach by gastrostomy are among the 
easiest in surgery and are successful. 

Remember that the establishment of a gastric 
fistula is to be done by either WiTzei/s, Marwe- 



210 GOIvDSN RUI^S OF SURGERY. 

dei/s or Frank's method or some modification of 
those named, as may be indicated by the object to 
be achieved. 

Remember that the Murphy button and other 
similar contrivances are no longer used by those 
who can make an anastomosis with a needle and 
thread. These mechanical contrivances as well as 
the elastic ligature,* which I gave up twenty years 
ago, should no longer be used for making intesti- 
nal anastomoses except in cases where a rapid op- 
eration on a dying patient seems indicated. 

Before operating on the stomach have it thor- 
oughly washed and leave a stomach tube in it dur- 
ing the operation if possible. 

Suture of intestines is an art which though not 
difficult to execute and not at all dangerous in 
itself, requires close attention to detail. The one 
principle underlying this manipulation is the ap- 
preciation of the physiological fact that serosa will 



*Over twenty years ago at a meeting of the Tri-state Medical Society, I 
reported this method of making gastroenterostomy and other anastomoses, 
but I found it a bad, unsurgical operation, even worse than the button. It 
now bears the name of an honorable colleague and has been used by 
surgeons with some degree of success, but I cannot concur in its recommenda- 
tion. The elastic ligature and the button will be abandoned by young, skill- 
ful operators. Old men who have used these devices will, of course, continue 
to use them. 



STOMACH AND INTESTINES. 211 

adhere to serosa by mere contact provided that 
the two surfaces are slightly irritated and are kept 
in contact long enough for the formation of organ- 
ized tissue. This process is called primary union 
and is accomplished with surprising rapidity. The 
interposition of epithelial tssue between the two 
serosas while the sutures are introduced is the 
main thing to be avoided. One line of sutures may 
be buried by a second and the second by a third, 
as may seem requisite to insure strength and 
safety. The hundreds of different suture methods 
which have been invented all depend upon the 
above mentioned quality of the serosa and must 
be studied and tested by the surgeon. Then he 
can choose the method with which he is successful 
and which suits his personal abilities and his own 
views of their efficiency. Some methods appeal to 
and are used with success by one surgeon, while 
other surgeons succeed equally well with other 
methods, so that I am constrained to advise young 
surgeons to try them all before making up their 
minds as to their relative merits or demerits. The 
above applies to both end to end and lateral suture 
of intestines to each other. I have found it a good 
rule never to judge of a method until I have tried 



212 



GOLDEN RULES OF SURGERY. 



it myself. A priori verdicts or opinions are always 
unreliable, often false and misleading. 

The treatment of intestinal obstruction can not 
be satisfactorily explained in a small work of this 
kind, and again I can only give you the principles 
on which to act.- 

If called to a case early have patient taken to a 
hospital with all conveniences and make an explo- 
rative section and follow this up with a radical re- 
moval of the obstruction. 

In all other cases, in which the patient has been 
medically treated until there is peritonitis, tympan- 
ites, faecal vomiting, etc., make one or more intes- 
tinal fistulae or artificial anus. Secondary opera- 
tion will be indicated later on if the patient's life 
be saved by the intestinal fistulae which have been 
established. 

Lateral anastomosis has its greatest usefulness 
where intestines of unequal caliber are to be 
joined. Under such circumstances end to end an- 
astomosis is difficult. 



THROAT. 213 



THROAT. 



Never neglect or think lightly of a stab wound 
of the neck. 

Remember that in stab wounds of the upper 
part of the neck with arterial bleeding, there is an 
impossibility in many cases of determining what is 
the exact source of the haemorrhage, so numerous 
are the great vessels in that region. Apply a lig- 
ature to common carotid or external carotid if un- 
controllable. 

Never neglect in cut throats where the trachea 
has been opened, to remove all small fragments 
which hang loose in the trachea, or they may swell 
and eventually stop respiration. 

Avoid skin sutures in cut throat when the wind 
pipe is opened;' always suture trachea, but the skin 
wound may be left to granulate; if muscles and 



214 goix>en rules of surgery. 

fasciae are cut some catgut sutures will do no 
harm and may hasten the healing process. 

Never put silk or silver ligatures into a wound- 
ed oesophagus ; only use catgut. 

Never forget that fractures of the laryngeal car- 
tilages are serious injuries. The nearer the cords, 
the acuter the symptoms, the more decisive must 
be the treatment. If the fragments are displaced 
and the mucous membrane lacerated or perforated 
by the fragments (as testified by emphysema and 
blood spitting), tracheotomy must be performed 
immediately. 

Remember that tracheotomy and insertion of 
the tube is especially necessary in wounded epiglot- 
tis or arytenoid cartilages. 

Never neglect in cases of dysphagia or violent 
dyspnoea in infancy, to examine the pharnyx for 
retro-pharyngeal abscess. 

Never neglect in all sudden dyspnoea in a child 
to pass your finger into the upper part of the larnyx 
to search for a foreign body. 

Sanction no delay in removing a foreign body 



THROAT. 215 

known to be in the larynx. Invert under anaes- 
thesia and if the body does not come away, do 
laryngotomy or tracheotomy. I have had to ex- 
tract foreign bodies from the bronchi below the 
bifurcation, when this rule was neglected, months 
after the accident. 

Never invert in cases of foreign body in the 
trachea, unless you have your tracheotomy instru- 
ments ready, for the danger of instant suffocation 
through lodging of the foreign body in the glottis 
is great. 

Never hesitate in foreign bodies in the trachea 
to invert the patient after the tracheal incision has 
been made for the extraction of the foreign body. 
Never use forceps, but invert and succuss the pa- 
tient, or use a hook, bent probe, or wire snare. 

Never forget that lung disease invariably ensues 
on the retention of a foreign body in the bronchus. 

Always keep the tracheotomy instruments by 
the bedside in cases of oedema of glottis due to 
syphilis, erysipelas, wounds, and especially scalds 
of glottis. 



216 



GOI^DEN RUIvSS OF SURGERY. 



Always secure your tracheotomy tube by knot- 
ting the tape. Little patients are apt to drag at 
and undo a bow. If the tube slips out and nurse 
is not present or handy at replacing it, a fatal re- 
sult may ensue. 

Either use the solid double tube or sew the 
trachea to the skin, so that breathing without a 
tube is free and easy in an emergency, where a 
tube can not be had. 

Remember the "lines of safety" for dividing 
fascia of neck, in dealing with cellulitis of neck : 

1. — Mesial line from chin to interclavicular 
notch. 

2. — Line along posterior border of sterno- 
cleido-mastoid, taking care to avoid the ex- 
ternal jugular vein. 

3. — Where there is a fluctuating, bulging ab- 
scess, it may be opened at its most promi- 
inent point, using the ordinary precautions. 



veins. 217 



VEINS. 



Do not excise or underpin a varicose vein if 
there is any suspicion of phlebitis, or if there is 
any inflamed condition of the area drained by the 
vein [e. g., inflamed ulcer of leg, with varicose 
vein]. 

I favor the excision of varicose veins if they 
become large and painful, after the method prac- 
tised by C. H. Mayo. The operation is extensive 
and is successful in the hands of skillful men and 
under thoroughly aseptic surroundings. Where 
you have the least doubt or lack of confidence in 
the cleanliness of the surroundings, do not operate. 
This rule applies to all operations as a matter of 
course, but I repeat it in this connection, because 
the removal of the varicose saphena vein opens up 
a vast field of lymphatics. Remember that all 
veins are surrounded by a very complete network 



218 



GOLDEN RULES OF SURGERY. 



of lymph channels and capillaries, in which strepto 
and staphylococci and other germs are very prone 
to thrive and rapidly to cause febrile and septic dis- 
turbances and death. 



REMINISCENCES. 219 



REMINISCENCES. 



When not yet eighteen years old, having ac- 
quired an American college education and the de- 
gree of B. A., I matriculated at the University of 
Heidelberg in 1872. After two years of study in 
anatomy, physiology, chemistry and histology, 
all practically laboratory work and dissection, 
I began the study of medicine and surgery. I had 
become enamored of anatomy and embryology, 
and the advent of Gegenbaur, the then greatest 
living morphologist, and FuERBRINGER, his prosec- 
tor, from the University of Jena, bringing with 
them the gospel of Darwinism and evolution, kept 
me in touch with biological science and its en- 
lightening influence on dry old anatomy. 

Under Gegenbaur anatomy took on a new in- 
terest, and under his guidance and in his labora- 
tory I began morphological work, which ended in 
my taking an embryological subject for my the- 



220 GOLDEN RUIZES OF SURGERY. 

sis. The results of my investigation turned out to 
the satisfaction of Gegenbaur and my thesis re- 
ceived the highest honors from the faculty, and in 
the final examination for the degree of M. D., I 
was awarded the summa cum laude. 

It was my intention to become an anatomist, to 
take up the academic career, but my father, who 
was a physician, said, "You must become a sur- 
geon if you wish to locate in America. An anat- 
omist cannot make a living in our country." 

The great surgeon, Gustav Simon, who made 
the first kidney extirpation, was the leading sur- 
geon and held daily clinics at the academic hos- 
pital. I soon became a favorite with him because 
of my accurate anatomical acquirements, my abil- 
ity to draw with pencil and chalk and my con- 
genital dexterity. 

In the summer of 1875 Mr. Joseph Lister came 
to Heidelberg staying a few days and himself 
showed us his antiseptic method and its technique, 
the carbolic spray, the protective silk, etc. One of 
the first cases upon which we used it was a com- 
pound comminuted fracture of the leg just below 
the knee. It healed almost without rise of tem- 
perature and without pus in a way that appeared 



REMINISCENCES. 221 

to us a miracle. Most compound fractures, in fact 
most amputations in those days, had chills and fever 
and died of septicaemia. The results of L,isterism 
for some years did not come up to expectations in 
the dirty old academic .hospital, where we used, 
sponges and where the attendants and nurses were 
not yet trained in antiseptics. A very heated con- 
troversy between surgeons pro and con took place. 
The majority of surgeons remained sceptical, but 
there were some who had new hospitals and re- 
ported results so much better than the old results 
that, of course, all were compelled to take up anti- 
septic methods. The Germans soon became con- 
vinced of the truth of the doctrine and finally went 
a step farther and introduced the aseptic method 
of operating and of wound-treatment under which 
we are all working now. This method is applica- 
ble to all clean cases and even to infected ones, if 
only rest is secured, by free drainage. I claim that 
the worst form of unrest is caused by bacteria 
and their toxines in the tissues. The term inflam- 
mation no doubt was useful, but it. now is only 
confusing and the notion of infection together with 
the tissue-unrest it produces would be a much bet- 
ter form of expression and I have here proposed it. 



222 GOLDEN RULES OF SURGERY. 

There is no reason why we must get all our the- 
ories of fever, infection, toxaemia, etc., from for- 
eigners. If I were not a busy operating surgeon, I 
would take the time and do the work to establish 
my view and rid the profession of the time-honored 
and misleading word inflammation. 

During the summer of 1876 I became an in- 
terne in the academic hospital, on the male divis- 
ion, and received the magnificent salary of fifty- 
two marks and some pennies, which were brought 
to me on the first of each month by a university or 
government official. Besides I had a large room and 
bedroom, first-class fare and a bottle of claret per 
diem. My associates were the other assistants, all 
of them now holding the highest honor-positions 
the medical profession affords in Europe. This 
position did not last many months because Simon 
died during the year 1876 of an aneurysm of the 
thoracic aorta. On the day when it burst, the poor 
fellow, honored and loved by us all, becoming dys- 
pnoeic, as the blood sickered out of the sac, com- 
pressing the lungs or bronchi, sent over to the hos- 
pital to have tracheotomy done, thinking it would 
relieve him. Henry Braun was first assistant, and 
although convinced of the uselessness of the oper- 



REMINISCENCES. 223 

ation, performed it under great difficulties, the 
veins of the neck being enormously distended. 
Marion Sims, whom I met while I was Simon's as- 
sistant, says in his obituary (American Journal of 
Obstetrics, 1876) : "The propriety of withholding 
from such a man the gravity of his disease seems 
to me questionable." Had he known he might 
have lived a little longer, he would have done 
less work. Which is the better? Of course he 
would not have undergone the tracheotomy which 
he insisted on having done without an anaesthetic. 
After the canula was introduced he declared him- 
self relieved, his pulse kept up until 10 o'clock, then 
he collapsed. Thus passed away one of the great 
lights of surgery. 

I owe him my introduction to surgery and 
more thanks than I can ever express. He showed 
me how to close vesico-vaginal fistulas, and he did 
it better than any man then living. I think that 
possibly now Howard Kelly can do it as well as he 
could. He showed me how to do plastic work on 
the face and he could use a needle and fine silk 
more effectually than any surgeon I ever saw put 
in sutures. His wounds looked neat when closed 
and he got first intention in his plastic work very 



224 GOLDEN RULES OE SURGERY. 

frequently without antiseptics, because he was nat- 
urally a clean man. 

After Simon's death I remained at the hospital 
a few months longer as an assistant to Lossen 
who during the interim filled the chair until 
CzERNY was called and a new hospital built. 

Bearing letters of introduction to von Eang- 
ENB-ECK, that prince of surgeons, I went to Berlin 
in October, 1876, and was soon installed as a pri- 
vate student of v. LangenbECk's. This man was 
undoubtedly the quickest and neatest operator of 
his generation, and not only that, he was also one 
of the most amiable and polite gentlemen in Eu- 
rope. So great was his reputation that he opera- 
ted on members of the Russian and English reign- 
ing houses. He made annual trips to England and 
spoke the English language very well. He gave a 
small class of us instruction in surgery on the cad- 
aver. One day he said to me : "A Scotchman, named 
Alexander Ogston, has invented a peculiar opera- 
tion for knock knees, a sort of subcutaneous oste- 
otomy of the internal condyle of the femur. Will 
you read it up and show it to us tomorrow morn- 
ing on the cadaver?" I did the operation on the 
cadaver the next morning at his course which he 



REMINISCENCES. 225 

gave at six o'clock A. M. He complimented me 
before the class on the manner in which I did the 
work. 

He was president of the German Society for 
Surgeons and was always re-elected by acclama- 
tion. He proposed me as a member and invited 
me to a dinner he gave at his home to the execu- 
tive council and foreign guests. I was the young- 
est of his guests. Dr. Fred Dennis, of New York, 
was also at the dinner, and speaking of that 
now celebrated surgeon, I may say it was his ad- 
vice to me which resulted in my going to England 
and taking the examination at the Royal College 
of Surgeons in London in 77. 

To Langenbeck I owe what I know about ele- 
gant and rapid operating, and also about the cure 
of cleft palate and complicated harelip as well as 
about some neurectomies and plastic operations 
on the eyelids and lips, but most particularly he 
had us practice subperiosteal resections. If I were 
to describe some of the feats I saw him do they 
would not be believed by many who did not see 
him operate. I will relate two surgical tricks he 
did in one day. He incised the perineum and ex- 
tracted a large stone from the bladder in one min- 



226 GOLDEN RULES OE SURGERY. 

ute. Next he exarticulated at the hip in sixteen 
seconds. I mean the limb was carried out by the 
attendant after sixteen seconds. It must be re- 
membered that he learned to operate from his un- 
cle in the days before they had anaesthetics. He 
related of one of his hip exarticulations done on a 
strong young soldier who was shot through the 
hip joint, that the fellow jumped out of bed and 
hopped after a nurse the third day after the oper- 
ation, trying to kiss her. Langenbeck's aristocratic 
manner and extreme politeness prevented undue 
familiarity, but he made us feel that he was our 
teacher and our friend upon whom we could rely for 
any act of friendship. 

I intended going to take a course under Bill- 
roth at Vienna, but upon making my farewell visit 
to von Langenbeck, he persuaded me to take a 
letter to the commanding general and to the chief 
surgeons of the Russian army who were then, in 
1877, fighting the Turks. In the letter he recom- 
mended me as peculiarly fit to be the chief of a 
field-hospital. Before I could reach the seat of 
war, however, peace was concluded, so that after 
all I could take a short course in surgery from 
Billroth in' Vienna who was just then doing all his 



REMINISCENCES. 227 

work under the spray. His results were pretty 
good, but I did not get much out of this great man, 
although he was kind enough to invite me to his 
laparotomies, which in those days were not every 
day occurrences. 

I remained in Vienna only about three and a 
half months. From there I returned to Heidelberg 
and made an anatomical investigation of the knee- 
joint and studied the embryology of joints in gen- 
eral under Gegenbaur. This memoir is published 
in the Morphologisches Jahresbuch of 1878 and 
contains but little that is of practical interest, but 
is considered of scientific importance. The Wash- 
ington University of St. Louis has acquired a com- 
plete set of this periodical recently and any one in- 
terested can see the contribution there. After a 
delightful time of a few months of intense embryo- 
logical work spiced by the association with some of 
the leading scientists from all parts of the earth at- 
tracted to Heidelberg by the name of Gegenbaur, 
I went to London for the examen. They know 
how to mix research work and social recreation in 
European scientific workshops. Many of the 
workers are very poor, living on a mere pittance, 
but they all save enough out of their incomes, be 



228 golden rules oe surgery. 

they ever so small, to take daily recreation, walk- 
ing about the mountains and having a glass of milk 
or beer with a sandwich at rural inns. 

In London I found the hospitals and medical 
schools in every way behind the German institu- 
tions and had the feeling that in histology, pathol- 
ogy and embryology the examiners were sadly 
lacking in the scientific, though well up in the prac- 
tical aspects of their various subjects. In antisep- 
tics even, though we look upon LiSTER as the foun- 
der and originator of the antiseptic wound-treat- 
ment, the Germans are the ones who have devel- 
oped and perfected the method and have given the 
scientific basis as well as practical usefulness to it. 

The one very pleasant recollection of the Lon- 
don term which sparkles even now after thirty 
years is an evening I spent in St. John's Wood at 
Mr. Huxley's house in his charming family circle. 
After I had spent about an hour talking about 
Gegenbaur and HaeckEL and the work at Heidel- 
berg, who should walk in but Mr. Chas. Darwin 
leaning on the arm of his wife. Of course I lis- 
tened with all my ears to the conversation between 
the two leading English scientists. This event left 
a lasting and deep impression and is the bright 



REMINISCENCES. 229 

spot in the otherwise foggy memories of London. 
Mr. Darwin was ill and nearly blind and allowed 
Mr. Huxley to make nearly all the conversation. 
It has been a great pleasure to express my deep 
gratitude to the teachers and masters who were 
kind enough to take an interest in me and I am free 
to say that they laid the foundation for whatever I 
have achieved. In turn I have tried to transmit 
and impart as much as I could to those w T ho have 
been my pupils or assistants. I feel very proud of 
some who have stood in this relation to me. Some 
of them are, I believe, conceded to rank with the 
best surgeons now living in this country. 



230 INDEX, 



INDEX, 



PAGE 

Abdomen 80 

Abscess 89 

Advice to Young Surgeons 10 

American Surgery 64 

Anaesthetics 75 

Anatomy 13 

Aneurysm 94 

Appendicitis 95 

Artery— Bleeding 102 

Asepsis and Rest 59 

Assistance and Assistants 192 

Autoptical vs. Autopsical 64 

Bile Function 32 

Bladder 139 

Bones 104 

Books , 194 

Breast 113 

Burns 115 

Cancer and Malignancy 205 

Chest 117 

Damage Suits 46, 47, 48 

Death Following Operation 25, 26, 68-70 

Didactic Teaching 17 

Dislocation : 133 

Drainage 87 

Drugs 63 

Bar 121 

Education by the State 63 

Education of a Surgeon 9 

Enthusiasm . 71 



INDEX. 231 



Erysipelas. 123 

Expert Testimony 47, 48, 49 

Fees 50 

Fistula and Sinus 93, 111 

Foot 158 

Fracture 126 

Gallstone Disease 136 

Gangrene 59, 138 

General 65 

Genital 139, 146 

Goitre 157 

Goitre, Intralingual 29, 30 

Gonorrhoea 148 

Hand 158 

Head 161 

Haemorrhage, Treatment 103 

Hernia 168 

Hernia — Radical Operation 170 

Inflammation 59, 173 

Infusion of Saline Solution 103, 20 L 

Intestinal Suture 210 

Ischaemic Atrophy from Tight Bandaging 131 

Joints 107 

Kidneys 150 

Literature 1 94 

Malpractice Suits . 49 

Moist Dressing „ :...-.. 178 

Mouth 181 

Nil Nocere 183' 

Nose ,. ... 183 

CEsophagus 185 



2o2 INDEX. 



Office Surgery 73 

Off With the Cloak 52 

On Ways and Means of Building Up Practice 43 

Operations 1 92 

Pelvis 197 

Penis 146 

Physiology 196 

Poisonous Medicines 62 

Preface 5 

Prescription Doctors 63 

Psychical Element 67 

Quacks and Charlatans 55 

Rectum 199 

Reminiscences 219 

Rubber Gloves 67 

Science and Surger}- 37 

Scientific Contributions 21 

Septic Fever 124 

Shock 200 

Skin Flaps 114 

vSkull Fractures and .Injuries 161 

Societies 43, 45 

Spine . 202 

Stomach 205 

Stone 142 

Syphilis 151 

Text-Books 15, 16 

Therapeutics— H ints 155 

Throat and Trachea . 213 

Time in Bed After Operations 86 

.Unsuccessful Surgeons 70 

Veins, Varicose . .- 217 

Warnings and Cautions 77 



Important New Medical Books that will be Ready Soon 

The Diagnosis and Treatment of the 
Medical Diseases of Women 



By H. S. Crossen, M. D., 

\ Gynaecology at the Washington 1 
St. Louis, Mo. 

300 Pages— Illustrated— PYice, $3.00. 



Professor of Gynaecology at the Washington University, 
St. Louis, Mo. 



The Golden Rules of Pediatrics 

Containing the Important Points in the Diag- 
nosis and Treatment of Diseases 
of Children 

By John Zahorsky, A. M., M. D., 

Clinical Professor of Diseases of Children at the Washington 
University, St. Louis, Mo. 

250 Pages— Cloth Binding— Price, $2.50. 



Sexual Hygiene and Its Relation 
to Health 

A Scientific Presentation of the Sexual Laws 
and the Rules for their Proper Enforcement 

By Joseph L,. Boehm, B. S., M. D., Ph. G., 

Professor of Genito-Urinary Diseases St. Louis College of 
Physicians and Surgeons, St. Louis, Mo. 

200 Pages— Cloth Binding— Price, $2.00. 



THE C. V. M0SBY MEDICAL BOOK CO., Publishers 
ST. LOUIS, MO. 



AN IMPORTANT BOOK READY 



EMERGENCY PRACTICE. 

Willcox's Emergency Practice and 
Formulary 

A Book Designee! for Ready Reference in 
Case of Accident and Injury 



Edited by T. A. Hopkins, A. M., M. D., 
St. Louis, Mo. 



CONTENTS: 

Fractures and Dislocations, Tracheotomy, 

Ligation of Arteries, Spasmodic Croup, 

Haemorrhages, Sunstroke, 

Wounds, Alcoholism, 

Anaesthesia, Hernia, 

Burns and Scalds, Stomach and Oesophagus, 

Unconsciousness, Eye Accidents, 

Asphyxia, Ear, Nose and Throat, 

Convulsions, OEdema of the Larynx, 

Normal Saline Solutions, Complications of Labor, 

Dyspnoea, Abortion, 
Antidotes to Poisons. 



300 Pages— Bound in Limp Leather — Pocket Size. 
Price, $1.00. 



THE C. V. MOSBY MEDICAE BOOK CO., Publishers 
ST. LOUIS, MO. 



OCT 29 









LIBRARY OF CONGRESS # 



027 325 123 6 



